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Deficiency Records for Lakeshore Post Acute and Rehabilitation Center
A list of the most recent deficiencies for Lakeshore Post Acute and Rehabilitation Center. 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 Lakeshore Post Acute and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-26 | 2024-01-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-20 | 2024-01-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-26 | 2023-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-12-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-26 | 2023-12-06 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-26 | 2023-11-24 | 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 | 2023-10-26 | 2023-11-24 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-26 | 2023-11-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-26 | 2023-11-24 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-10-26 | 2023-11-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-26 | 2023-11-24 | 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 | 2023-10-26 | 2023-11-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-11-24 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-10-26 | 2023-11-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Develop a communication plan. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Establish methods for sharing information. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-26 | 2023-11-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-04-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-09 | 2023-04-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-04-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-09 | 2023-04-06 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-28 | 2022-11-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-28 | 2022-08-22 | 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 | 2022-07-28 | 2022-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-28 | 2022-08-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-28 | 2022-08-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-28 | 2022-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-28 | 2022-08-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-28 | 2022-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-28 | 2022-08-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-07 | 2022-07-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-07 | 2022-07-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-07 | 2022-07-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-07 | 2022-07-30 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2022-07-28 | 2022-07-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-05 | 2021-06-16 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2021-05-05 | 2021-06-04 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-05-05 | 2021-06-04 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-05-05 | 2021-05-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-05 | 2021-05-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-05 | 2021-05-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-05-05 | 2021-05-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-05 | 2021-05-07 | 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 | 2021-05-05 | 2021-05-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-05 | 2021-05-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-07 | 2021-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-07 | 2021-04-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-04-07 | 2021-04-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-20 | Not Fixed | N |
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