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Deficiency Records for Edenbrook Lakeside
A list of the most recent deficiencies for Edenbrook Lakeside. 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 Edenbrook Lakeside. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-27 | 2024-03-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-27 | 2024-03-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-24 | 2024-03-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-10 | 2024-03-05 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-01-24 | 2024-02-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-06 | 2024-01-02 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-12-06 | 2024-01-02 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-18 | 2023-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-18 | 2023-12-28 | 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 | 2023-09-18 | 2023-10-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-19 | 2023-10-17 | 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 | 2023-09-19 | 2023-10-17 | 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 | 2023-09-19 | 2023-10-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-19 | 2023-10-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-19 | 2023-10-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-19 | 2023-10-17 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-09-18 | 2023-10-13 | 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 | 2023-09-18 | 2023-10-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-18 | 2023-10-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-18 | 2023-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-18 | 2023-10-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-25 | 2022-06-24 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-05-25 | 2022-06-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-25 | 2022-06-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-25 | 2022-06-24 | 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 | 2022-05-25 | 2022-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-06-24 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-25 | 2022-06-24 | Y |
| Post nurse staffing information every day. | Health | 2022-05-25 | 2022-06-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-25 | 2022-06-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-25 | 2022-06-24 | 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 | 2022-05-23 | 2022-06-24 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-05-23 | 2022-06-24 | 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 | 2022-05-23 | 2022-06-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-23 | 2022-06-24 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-01 | 2022-03-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-28 | 2022-02-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-28 | 2022-02-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-27 | 2021-11-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-27 | 2021-11-25 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-02-11 | 2021-03-11 | 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 | 2021-02-11 | 2021-03-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-11 | 2021-03-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-11 | 2021-03-11 | 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 | 2021-02-11 | 2021-03-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-02-11 | 2021-03-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-02-11 | 2021-03-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-02-10 | 2021-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-10 | 2021-03-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-02-10 | 2021-03-11 | N |
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