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Deficiency Records for Ecumen Lakeshore

A list of the most recent deficiencies for Ecumen Lakeshore. 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 Ecumen Lakeshore. 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?
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-06-13 2024-06-25 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 2024-06-11 2024-06-25 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-06-11 2024-06-25 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-06-11 2024-06-25 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2024-06-11 2024-06-25 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-06-11 2024-06-25 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-06-11 2024-06-25 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-09-08 2023-10-09 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 2023-09-08 2023-10-09 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 2023-09-08 2023-10-09 N
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2023-09-08 2023-10-09 N
Provide and implement an infection prevention and control program. Health 2023-09-08 2023-10-09 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-09-05 2023-10-06 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-09-05 2023-10-06 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-09-05 2023-10-01 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-09-05 2023-09-30 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 2023-09-05 2023-09-25 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-09-05 2023-09-25 N
Post nurse staffing information every day. Health 2022-11-08 2022-12-08 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-05-25 2022-07-09 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 2022-05-25 2022-07-09 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 2022-05-25 2022-07-09 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-05-25 2022-07-09 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-05-25 2022-07-09 Y
Respond appropriately to all alleged violations. Health 2022-05-25 2022-07-09 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-05-25 2022-07-09 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-05-25 2022-07-09 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-05-25 2022-07-09 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2022-05-23 2022-07-09 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2022-05-23 2022-07-09 N

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