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Deficiency Records for Lotus Village Center For Nursing and Rehabilitation
A list of the most recent deficiencies for Lotus Village Center For Nursing and Rehabilitation. 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 Lotus Village Center For Nursing and Rehabilitation. 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 | 2024-08-07 | 2024-08-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-07 | 2024-08-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-07 | 2024-08-29 | 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 | 2024-03-19 | 2024-06-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-19 | 2024-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-19 | 2024-06-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-08 | 2024-05-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-08 | 2024-05-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-08 | 2024-05-04 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-04-08 | 2024-05-04 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-02-22 | 2024-05-04 | 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 | 2024-02-22 | 2024-05-04 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-02-22 | 2024-05-04 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-22 | 2024-05-04 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-22 | 2024-05-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-22 | 2024-05-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-22 | 2024-05-04 | 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 | 2024-02-22 | 2024-05-04 | 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 | 2024-02-22 | 2024-05-04 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-22 | 2024-05-04 | Y |
| 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 | 2024-02-22 | 2024-05-04 | 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 | 2024-02-22 | 2024-05-04 | 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 | 2024-02-22 | 2024-05-04 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-22 | 2024-05-04 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-22 | 2024-05-04 | Y |
| 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 | 2024-02-22 | 2024-05-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-12 | 2023-08-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-12 | 2023-08-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-12 | 2023-08-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-12 | 2023-08-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-28 | 2023-01-05 | Y |
| 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 | 2022-10-13 | 2022-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-13 | 2022-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-13 | 2022-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-14 | 2022-10-28 | 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 | 2022-09-14 | 2022-10-28 | 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 | 2022-09-14 | 2022-10-28 | 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 | 2022-09-14 | 2022-10-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-14 | 2022-10-28 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-09-14 | 2022-10-28 | 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 | 2022-09-14 | 2022-10-28 | 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 | 2022-09-14 | 2022-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-14 | 2022-10-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-14 | 2022-10-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-14 | 2022-10-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-14 | 2022-10-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-14 | 2022-10-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-14 | 2022-10-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-28 | Y |
| Post nurse staffing information every day. | Health | 2022-01-18 | 2022-02-17 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-01-18 | 2022-02-17 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-01-18 | 2022-02-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-18 | 2022-02-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-18 | 2022-02-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-18 | 2022-02-17 | Y |
| 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 | 2021-04-13 | 2021-05-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-12 | 2021-04-09 | N |
| 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 | 2021-03-12 | 2021-04-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-12 | 2021-04-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-12 | 2021-04-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-12 | 2021-04-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-12 | 2021-04-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-12 | 2021-04-09 | N |
| Post nurse staffing information every day. | Health | 2021-03-12 | 2021-04-09 | 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 | 2021-03-12 | 2021-04-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-12 | 2021-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-12 | 2021-04-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-12 | 2021-04-09 | N |
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