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Deficiency Records for Lakeside Manor Nursing and Rehabilitation Center

A list of the most recent deficiencies for Lakeside Manor 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 Lakeside Manor 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?
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 2024-07-16 2024-09-06 Y
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 2024-07-16 2024-09-06 Y
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2024-07-16 2024-09-06 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-07-16 2024-09-06 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-07-16 2024-09-06 N
Provide properly protected cooking facilities. Fire Safety 2024-07-16 2024-09-06 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-07-16 2024-09-06 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-07-16 2024-09-06 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-07-16 2024-09-06 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2024-07-16 2024-09-06 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-07-16 2024-09-06 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2024-07-16 2024-09-06 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-07-16 2024-09-06 N
Establish policies and procedures for medical documentation. Fire Safety 2024-07-16 2024-09-04 N
Establish policies and procedures for volunteers. Fire Safety 2024-07-16 2024-09-04 N
List the names and contact information of those in the facility. Fire Safety 2024-07-16 2024-09-04 N
Conduct testing and exercise requirements. Fire Safety 2024-07-16 2024-09-04 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 2024-07-16 2024-08-08 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2024-07-16 2024-08-08 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-07-16 2024-08-08 Y
Reasonably accommodate the needs and preferences of each resident. Health 2024-07-16 2024-08-08 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-07-16 2024-08-08 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-07-16 2024-08-08 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-07-16 2024-08-08 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-07-16 2024-08-08 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-07-16 2024-08-08 Y
Provide activities to meet all resident's needs. Health 2024-07-16 2024-08-08 Y
Ensure the activities program is directed by a qualified professional. Health 2024-07-16 2024-08-08 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-07-16 2024-08-08 Y
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 2024-07-16 2024-08-08 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 2024-07-16 2024-08-08 Y
Post nurse staffing information every day. Health 2024-07-16 2024-08-08 Y
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2024-07-16 2024-08-08 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-07-16 2024-08-08 Y
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2024-07-16 2024-08-08 Y
Provide and implement an infection prevention and control program. Health 2024-07-16 2024-08-08 Y
Keep all essential equipment working safely. Health 2024-07-16 2024-08-08 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-07-16 2024-08-08 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 2024-07-16 2024-08-08 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-07-16 2024-08-08 N
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Fire Safety 2024-07-16 2024-08-08 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-07-16 2024-08-08 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-07-16 2024-08-08 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-07-16 2024-08-08 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-07-16 2024-08-08 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-02-29 2024-03-18 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-02-29 2024-03-18 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-10-09 2023-10-25 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-10-09 2023-10-25 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-06-28 2023-07-12 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 2023-06-28 2023-07-12 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-06-28 2023-07-12 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-06-28 2023-07-12 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-05-10 2023-06-16 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 2023-05-10 2023-06-16 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-05-10 2023-06-16 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-05-10 2023-06-16 N
Provide and implement an infection prevention and control program. Health 2023-05-10 2023-06-16 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-05-10 2023-06-16 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 2023-05-10 2023-06-16 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-05-10 2023-06-16 Y
Establish policies and procedures for volunteers. Fire Safety 2023-05-08 2023-06-16 N
Conduct testing and exercise requirements. Fire Safety 2023-05-08 2023-06-16 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-05-08 2023-06-16 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 2023-05-08 2023-06-16 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2023-05-08 2023-06-16 N
Provide properly protected cooking facilities. Fire Safety 2023-05-08 2023-06-16 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-05-08 2023-06-16 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-05-08 2023-06-16 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-05-08 2023-06-16 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-05-08 2023-06-16 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-05-08 2023-06-16 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-05-08 2023-06-16 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-05-08 2023-06-16 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-05-08 2023-06-16 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-05-08 2023-06-16 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-05-08 2023-06-16 N
Meet requirements for the use and maintenance of medical gas equipment. Fire Safety 2023-05-08 2023-06-16 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-04-05 2023-04-27 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2023-04-05 2023-04-27 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2023-04-05 2023-04-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-04-05 2023-04-27 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 2022-10-04 2022-11-08 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-10-04 2022-11-08 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 2022-04-05 2022-09-07 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 2022-04-05 2022-09-07 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-04-05 2022-09-07 N
Respond appropriately to all alleged violations. Health 2022-04-05 2022-09-07 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 2022-04-05 2022-09-07 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-04-05 2022-09-07 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-04-05 2022-09-07 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 2022-04-05 2022-09-07 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2022-08-19 2022-08-31 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-08-19 2022-08-31 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2022-08-19 2022-08-31 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-08-19 2022-08-31 Y
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 2022-08-19 2022-08-31 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-19 2022-08-31 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 2022-08-19 2022-08-31 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 2022-08-19 2022-08-31 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 2022-08-19 2022-08-31 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2022-08-19 2022-08-31 Y
Provide and implement an infection prevention and control program. Health 2022-08-19 2022-08-31 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-08-19 2022-08-31 Y
Provide a means of sharing information on occupancy/needs. Fire Safety 2022-03-30 2022-07-13 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 2022-03-30 2022-07-13 N
Provide properly protected cooking facilities. Fire Safety 2022-03-30 2022-07-13 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-03-30 2022-07-13 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-03-30 2022-07-13 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-03-30 2022-05-20 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2022-03-30 2022-05-20 N
Establish policies and procedures for sheltering. Fire Safety 2022-03-30 2022-05-20 N
Create arrangements with other facilities to receive patients. Fire Safety 2022-03-30 2022-05-20 N
Develop a communication plan. Fire Safety 2022-03-30 2022-05-20 N
Provide emergency officials' contact information. Fire Safety 2022-03-30 2022-05-20 N
Conduct testing and exercise requirements. Fire Safety 2022-03-30 2022-05-20 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2022-03-30 2022-05-20 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2022-03-30 2022-05-20 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-03-30 2022-05-20 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-03-30 2022-05-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-03-30 2022-05-20 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-03-30 2022-05-20 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-04-05 2022-05-15 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2022-04-05 2022-05-15 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-04-05 2022-05-15 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2022-04-05 2022-05-15 N
Prepare residents for a safe transfer or discharge from the nursing home. Health 2022-04-05 2022-05-15 N
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Health 2022-04-05 2022-05-15 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-04-05 2022-05-15 N
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2022-04-05 2022-05-15 N
Honor each resident's preferences, choices, values and beliefs. Health 2022-04-05 2022-05-15 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-04-05 2022-05-15 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 2022-04-05 2022-05-15 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-04-05 2022-05-15 N
Provide enough food/fluids to maintain a resident's health. Health 2022-04-05 2022-05-15 N
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 2022-04-05 2022-05-15 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-04-05 2022-05-15 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-04-05 2022-05-15 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2022-04-05 2022-05-15 N
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 2022-04-05 2022-05-15 N
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 2022-04-05 2022-05-15 N
Post nurse staffing information every day. Health 2022-04-05 2022-05-15 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-04-05 2022-05-15 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 2022-04-05 2022-05-15 N
Ensure that residents are free from significant medication errors. Health 2022-04-05 2022-05-15 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 2022-04-05 2022-05-15 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2022-04-05 2022-05-15 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2022-04-05 2022-05-15 N
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 2022-04-05 2022-05-15 N
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2022-04-05 2022-05-15 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-04-05 2022-05-15 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-04-05 2022-05-15 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2022-04-05 2022-05-15 N
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Health 2022-04-05 2022-05-15 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-04-05 2022-05-15 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2022-04-05 2022-05-15 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-04-05 2022-05-15 N
Provide and implement an infection prevention and control program. Health 2022-04-05 2022-05-15 N
Implement a program that monitors antibiotic use. Health 2022-04-05 2022-05-15 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-04-05 2022-05-15 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 2022-04-05 2022-05-15 N
Ensure staff are vaccinated for COVID-19 Health 2022-04-05 2022-05-15 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-01-21 2022-02-22 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-01-21 2022-02-22 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-01-21 2022-02-22 Y
Ensure that residents are free from significant medication errors. Health 2022-01-21 2022-02-22 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-11-23 2022-02-22 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-11-03 2022-02-22 Y
Respond appropriately to all alleged violations. Health 2021-11-23 2021-12-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-11-23 2021-12-27 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-11-03 2021-12-27 Y
Respond appropriately to all alleged violations. Health 2021-11-03 2021-12-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-11-03 2021-12-27 Y

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