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Deficiency Records for Lakeshore Manor Nursing and Rehab
A list of the most recent deficiencies for Lakeshore Manor Nursing and Rehab. 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 Manor Nursing and Rehab. 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 | 2024-08-27 | 2024-09-11 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-27 | 2024-09-11 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-08-27 | 2024-09-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-27 | 2024-09-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-17 | 2024-08-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-17 | 2024-08-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-09 | 2024-08-16 | N |
| Post nurse staffing information every day. | Health | 2024-07-09 | 2024-08-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-07-09 | 2024-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-09 | 2024-08-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-09 | 2024-08-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-09 | 2024-08-16 | Y |
| 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 | 2024-07-09 | 2024-08-16 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-07-09 | 2024-08-16 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-07-09 | 2024-08-16 | 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 | 2024-07-02 | 2024-08-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-02 | 2024-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-02 | 2024-08-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-13 | 2024-04-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-11 | 2024-02-15 | 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 | 2024-01-11 | 2024-02-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-11 | 2024-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-02-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-11 | 2024-02-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-11 | 2024-02-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-15 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-01-11 | 2024-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-11 | 2024-02-15 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2024-01-11 | 2024-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-04 | 2023-12-22 | Y |
| 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 | 2023-11-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-14 | 2023-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-16 | 2023-09-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-08 | 2023-08-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-08 | 2023-08-26 | 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 | 2023-08-08 | 2023-08-26 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-08-08 | 2023-08-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-08 | 2023-08-26 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-07-13 | 2023-08-22 | 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 | 2023-07-13 | 2023-08-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-07-13 | 2023-08-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-13 | 2023-08-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-13 | 2023-08-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-13 | 2023-08-22 | 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 | 2023-07-13 | 2023-08-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-13 | 2023-08-22 | 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 | 2023-07-13 | 2023-08-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-13 | 2023-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-13 | 2023-08-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-13 | 2023-08-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-07-13 | 2023-08-22 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-07-11 | 2023-08-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-11 | 2023-08-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-05 | 2023-05-18 | 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 | 2023-04-05 | 2023-05-18 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-05 | 2023-05-18 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-04-05 | 2023-05-18 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-04-05 | 2023-05-18 | 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 | 2023-04-05 | 2023-05-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-05 | 2023-05-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-02 | 2023-03-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-02 | 2023-03-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-30 | 2023-01-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-30 | 2023-01-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-30 | 2023-01-12 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-03-09 | 2022-03-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-09 | 2022-03-25 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-21 | 2022-03-05 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-21 | 2022-03-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-03 | 2022-01-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-03 | 2022-01-10 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-12-03 | 2022-01-10 | 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 | 2021-12-03 | 2022-01-10 | 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 | 2021-12-03 | 2022-01-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-03 | 2022-01-10 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-03 | 2022-01-10 | Y |
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