A list of the most recent deficiencies for Haven of 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-08 | 2023-02-24 | N |
| 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 | 2022-12-08 | 2023-02-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-12-08 | 2023-02-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-08 | 2023-02-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-08 | 2023-02-24 | 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 | 2022-12-08 | 2023-02-24 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-12-08 | 2023-02-24 | 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 | 2022-12-08 | 2023-02-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-08 | 2023-02-24 | 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 | 2022-12-08 | 2023-02-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-08 | 2023-02-24 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-08 | 2023-02-24 | 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 | 2022-12-08 | 2023-02-24 | 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 | 2022-12-08 | 2023-02-24 | 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 | 2021-07-15 | 2021-08-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-15 | 2021-08-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-15 | 2021-08-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-15 | 2021-08-19 | 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 | 2021-07-15 | 2021-08-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-15 | 2021-08-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-08-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-19 | 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 | 2021-07-15 | 2021-08-19 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-07-15 | 2021-08-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-15 | 2021-08-19 | 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 | 2021-07-15 | 2021-08-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-15 | 2021-08-19 | 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 | 2021-07-15 | 2021-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-16 | 2021-08-16 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-07-16 | 2021-08-16 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-07-16 | 2021-08-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-16 | 2021-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-29 | 2019-06-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-29 | 2019-06-03 | 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 | 2019-03-27 | 2019-05-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-27 | 2019-05-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-27 | 2019-05-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-27 | 2019-05-13 | N |
