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Deficiency Records for Holmes Lake Rehabilitation and Care Center
A list of the most recent deficiencies for Holmes Lake Rehabilitation and Care 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 Holmes Lake Rehabilitation and Care 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-10-08 | 2024-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-10-08 | 2024-11-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-08 | 2024-11-20 | 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 | 2024-10-08 | 2024-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-08 | 2024-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-08 | 2024-11-20 | 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 | 2024-10-08 | 2024-11-20 | N |
| Meet other general requirements. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-01 | 2024-11-20 | 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 | 2024-10-01 | 2024-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-10-01 | 2024-11-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-13 | 2024-04-20 | 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 | 2023-11-29 | 2024-03-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-11-29 | 2024-01-25 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-11-29 | 2024-01-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-30 | 2024-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-30 | 2024-01-10 | N |
| Post nurse staffing information every day. | Health | 2023-11-30 | 2024-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-01-10 | 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 | 2023-11-30 | 2024-01-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2024-01-10 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-06 | 2023-10-10 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-08 | 2022-12-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-08 | 2022-12-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-08 | 2022-12-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-08 | 2022-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-08 | 2022-12-31 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-08 | 2022-12-31 | N |
| 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 | 2022-11-08 | 2022-12-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-08 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-08 | 2022-12-31 | 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 | 2022-11-08 | 2022-12-31 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-08 | 2022-12-31 | 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 | 2022-11-08 | 2022-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
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