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Deficiency Records for Lakehouse Healthcare and Rehabilitation Center
A list of the most recent deficiencies for Lakehouse Healthcare 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 Lakehouse Healthcare 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 | 2024-08-01 | 2024-09-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-01 | 2024-09-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-01 | 2024-09-17 | 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 | 2024-08-01 | 2024-09-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-01 | 2024-09-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-01 | 2024-09-17 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-08-01 | 2024-09-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-01 | 2024-09-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-01 | 2024-09-17 | 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 | 2024-08-01 | 2024-09-17 | 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 | 2024-08-01 | 2024-09-17 | 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 | 2024-08-01 | 2024-09-17 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-08-01 | 2024-09-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-01 | 2024-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-01 | 2024-09-17 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-01 | 2024-09-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-01 | 2024-09-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-01 | 2024-09-17 | 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 | 2024-08-01 | 2024-09-17 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-01 | 2024-09-17 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-08-01 | 2024-09-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | 2024-09-17 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-01 | 2024-09-17 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2024-08-01 | 2024-09-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-08-01 | 2024-09-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2024-07-30 | 2024-09-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-06-10 | 2024-07-16 | 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 | 2024-06-10 | 2024-07-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-10 | 2024-07-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-24 | 2024-05-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-08 | 2024-03-29 | 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 | 2024-01-11 | 2024-02-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-28 | 2024-02-06 | 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 | 2023-12-28 | 2024-02-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-10 | 2023-09-01 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-29 | 2023-09-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-29 | 2023-09-01 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-06-29 | 2023-09-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-29 | 2023-09-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-09-01 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-29 | 2023-09-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-09-01 | 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 | 2023-06-29 | 2023-09-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-09-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-06-29 | 2023-09-01 | 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 | 2023-06-29 | 2023-09-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-29 | 2023-09-01 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-29 | 2023-09-01 | 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 | 2023-06-29 | 2023-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-09-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-29 | 2023-09-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-29 | 2023-09-01 | 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 | 2023-06-29 | 2023-09-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-09-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-29 | 2023-09-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-29 | 2023-09-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-28 | 2023-09-01 | 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 | 2023-06-28 | 2023-09-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Have an externally vented heating system. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-28 | 2023-09-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-28 | 2023-07-12 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-06-28 | 2023-06-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-10 | 2022-11-30 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2022-11-10 | 2022-11-30 | 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 | 2022-11-10 | 2022-11-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-26 | 2022-11-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-15 | 2022-10-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-27 | 2022-08-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-23 | 2022-07-31 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-23 | 2022-07-31 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-30 | 2021-11-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-30 | 2021-11-23 | 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 | 2021-09-30 | 2021-11-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-30 | 2021-11-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-30 | 2021-11-10 | 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 | 2021-09-30 | 2021-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-30 | 2021-11-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-30 | 2021-11-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-04 | 2021-11-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-04 | 2021-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-04 | 2021-11-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-04 | 2021-11-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-30 | 2021-11-10 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-10-04 | 2021-10-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-04 | 2021-10-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-04 | 2021-10-29 | N |
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