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Deficiency Records for Lake Woods Nursing and Rehabilitation Center
A list of the most recent deficiencies for Lake Woods Nursing 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 Lake Woods Nursing 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 | 2024-08-19 | 2024-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-19 | 2024-09-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-20 | 2024-07-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-12 | 2024-07-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-20 | 2024-06-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-20 | 2024-06-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-05-20 | 2024-06-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-20 | 2024-06-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-20 | 2024-06-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-20 | 2024-06-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-20 | 2024-06-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-20 | 2024-06-18 | Y |
| 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 | 2024-05-20 | 2024-06-18 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-05-20 | 2024-06-18 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-05-20 | 2024-06-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-20 | 2024-06-18 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-05-20 | 2024-06-18 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-05-14 | 2024-06-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-22 | 2024-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-22 | 2024-03-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-22 | 2024-03-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-22 | 2024-03-29 | 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 | 2024-02-22 | 2024-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-12 | 2023-10-13 | 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 | 2023-09-12 | 2023-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-12 | 2023-06-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-27 | 2023-05-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-27 | 2023-05-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-27 | 2023-05-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-27 | 2023-05-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-27 | 2023-05-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-27 | 2023-05-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-27 | 2023-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-02 | 2022-06-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-03 | 2022-04-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-03 | 2022-04-13 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-03-03 | 2022-04-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-03 | 2022-04-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-03 | 2022-04-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-03 | 2022-04-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-03 | 2022-04-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-03 | 2022-04-13 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-02 | 2022-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-02 | 2022-03-03 | N |
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