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Deficiency Records for Five Points at Lake Highlands Nursing and Rehab
A list of the most recent deficiencies for Five Points at Lake Highlands Nursing and Rehab. 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 Five Points at Lake Highlands Nursing and Rehab. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-12-10 | 2024-12-12 | 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 | 2024-12-10 | 2024-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-12-10 | 2024-12-12 | N |
| 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 | 2024-12-10 | 2024-12-12 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-12-10 | 2024-12-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-12-10 | 2024-12-12 | 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 | 2024-12-10 | 2024-12-12 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-12-10 | 2024-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-12-10 | 2024-12-12 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| 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 | 2024-12-10 | 2024-12-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-12-10 | 2024-12-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-12-06 | 2024-12-08 | Y |
| 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 | 2024-12-06 | 2024-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-12-06 | 2024-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-03 | 2024-06-03 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-05-18 | 2024-05-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-20 | 2024-01-22 | Y |
| 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 | 2024-01-20 | 2024-01-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-20 | 2024-01-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-20 | 2024-01-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-11 | 2023-11-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-07 | 2023-11-24 | 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 | 2023-11-07 | 2023-11-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-07 | 2023-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-07 | 2023-11-24 | N |
| Have policies on smoking. | Health | 2023-11-07 | 2023-11-24 | 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 | 2023-11-09 | 2023-11-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-09 | 2023-11-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-09 | 2023-11-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-09 | 2023-11-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-09 | 2023-11-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-09 | 2023-11-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-09 | 2023-11-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-05 | 2023-06-30 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-05 | 2023-06-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-07 | 2023-05-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-24 | 2023-03-31 | Y |
| 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 | 2022-12-06 | 2023-01-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-06 | 2023-01-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-15 | 2022-10-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-15 | 2022-10-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-15 | 2022-10-21 | Y |
| 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 | 2022-09-15 | 2022-10-21 | 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 | 2022-09-15 | 2022-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-15 | 2022-10-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-15 | 2022-10-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-15 | 2022-10-21 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-07-19 | 2022-08-19 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-19 | 2022-08-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-19 | 2022-08-19 | Y |
| Provide appropriate foot care. | Health | 2022-07-19 | 2022-08-19 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-07-19 | 2022-08-19 | Y |
| 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 | 2022-05-17 | 2022-06-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-17 | 2022-06-10 | Y |
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