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Deficiency Records for Clove Lakes Health Care and Rehab Center, Inc
A list of the most recent deficiencies for Clove Lakes Health Care and Rehab Center, Inc. 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 Clove Lakes Health Care and Rehab Center, Inc. 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-11-10 | 2023-01-09 | 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 | 2022-11-10 | 2023-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2023-01-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-10 | 2023-01-09 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-11-10 | 2023-01-09 | 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 | 2022-11-10 | 2023-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-10 | 2023-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2023-01-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-10 | 2023-01-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-10 | 2023-01-09 | Y |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-10 | 2023-01-09 | 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 | 2022-11-10 | 2023-01-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-10 | 2023-01-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-23 | 2020-03-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-23 | 2020-03-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-23 | 2020-03-22 | 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 | 2020-01-23 | 2020-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-23 | 2020-03-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-01-23 | 2020-03-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-23 | 2020-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-23 | 2020-03-22 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2020-01-23 | 2020-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-23 | 2020-03-22 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-04-27 | 2018-06-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-04-27 | 2018-06-22 | 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 | 2018-04-27 | 2018-06-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-04-27 | 2018-06-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-27 | 2018-06-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-04-27 | 2018-06-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-27 | 2018-06-22 | N |
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