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Deficiency Records for Locust Grove Retirement Village
A list of the most recent deficiencies for Locust Grove Retirement Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Locust Grove Retirement Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-06-18 | 2024-07-05 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-05-15 | 2024-06-29 | N |
| Meet other general requirements. | Fire Safety | 2024-05-15 | 2024-06-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-15 | 2024-06-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-15 | 2024-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-15 | 2024-06-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-05-15 | 2024-06-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-05-03 | 2024-06-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-05-03 | 2024-06-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-03 | 2024-06-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-03 | 2024-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-03 | 2024-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-03 | 2024-06-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-05-03 | 2024-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-03 | 2024-06-14 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-05-03 | 2024-06-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-05-03 | 2024-06-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-05-03 | 2024-06-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-03 | 2024-06-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-03 | 2024-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-03 | 2024-06-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-03 | 2024-06-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-03 | 2024-06-14 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-05-03 | 2024-06-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-03 | 2024-03-28 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-22 | 2023-10-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-22 | 2023-10-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-22 | 2023-10-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-04 | 2023-08-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-04 | 2023-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-04 | 2023-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-04 | 2023-08-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-04 | 2023-08-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-04 | 2023-08-29 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-08-04 | 2023-08-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-04 | 2023-08-29 | N |
| Provide or obtain dental services for each resident. | Health | 2023-08-04 | 2023-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-04 | 2023-08-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-04 | 2023-08-29 | N |
| Meet other general requirements. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-12 | 2022-09-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-12 | 2022-09-21 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-12 | 2022-09-21 | Y |
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