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Deficiency Records for Eagle Lake Nursing and Rehab Care Center
A list of the most recent deficiencies for Eagle Lake Nursing and Rehab Care 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 Eagle Lake Nursing and Rehab Care 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? |
|---|---|---|---|---|
| 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 | 2024-08-29 | 2024-09-29 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-08-29 | 2024-09-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-29 | 2024-09-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-29 | 2024-09-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-29 | 2024-09-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-29 | 2024-09-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-29 | 2024-09-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-29 | 2024-09-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-29 | 2024-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-29 | 2024-09-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-08-29 | 2024-09-29 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-08-29 | 2024-09-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-29 | 2024-09-29 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-29 | 2024-09-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-08-27 | 2024-09-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-27 | 2024-09-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-27 | 2024-09-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-27 | 2024-09-29 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-08-27 | 2024-09-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-27 | 2024-09-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-27 | 2024-09-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-08-27 | 2024-09-29 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-02 | 2023-12-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-12-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-02 | 2023-12-20 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-02 | 2023-12-20 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-02 | 2023-12-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-02 | 2023-12-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-02 | 2023-12-20 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-07 | 2023-09-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-07 | 2023-09-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-07 | 2023-09-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-07 | 2023-09-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-24 | 2023-03-26 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-24 | 2023-03-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-24 | 2023-03-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-24 | 2023-03-26 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-24 | 2023-03-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-24 | 2023-03-26 | Y |
| 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 | 2022-09-08 | 2022-10-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-08 | 2022-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-08 | 2022-10-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-08 | 2022-10-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-08 | 2022-10-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-08 | 2022-10-08 | N |
| Meet other general requirements. | Fire Safety | 2022-09-07 | 2022-10-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-07 | 2022-10-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-18 | 2021-07-10 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-03-18 | 2021-07-10 | 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 | 2021-03-18 | 2021-04-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-03-18 | 2021-04-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-18 | 2021-04-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-18 | 2021-04-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-18 | 2021-04-18 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-18 | 2021-04-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-18 | 2021-04-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-18 | 2021-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-18 | 2021-04-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-18 | 2021-04-18 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-03-18 | 2021-04-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
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