A list of the most recent deficiencies for Lighthouse Healthcare Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-19 | 2024-02-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-12 | 2023-12-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-02-07 | 2023-02-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-28 | 2022-12-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-13 | 2022-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-29 | 2022-06-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-04-29 | 2022-06-02 | 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 | 2022-04-29 | 2022-06-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-29 | 2022-06-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-04-29 | 2022-06-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-29 | 2022-06-02 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-29 | 2022-06-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-29 | 2022-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-29 | 2022-06-02 | 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 | 2022-04-29 | 2022-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-29 | 2022-06-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-29 | 2022-06-02 | 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 | 2022-04-29 | 2022-06-02 | 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 | 2022-04-29 | 2022-06-02 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-04-29 | 2022-06-02 | 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 | 2022-04-29 | 2022-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-29 | 2022-06-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-29 | 2022-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-29 | 2022-06-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-04-27 | 2022-05-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-27 | 2022-05-19 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-04-27 | 2022-05-19 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-04-27 | 2022-05-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-27 | 2022-05-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-27 | 2022-05-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-27 | 2022-05-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-27 | 2022-05-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-05 | 2022-05-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-22 | 2021-06-02 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-04-22 | 2021-06-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-13 | 2019-10-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-09-13 | 2019-10-10 | 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 | 2019-09-13 | 2019-10-10 | 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 | 2019-09-13 | 2019-10-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-13 | 2019-10-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-13 | 2019-10-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-13 | 2019-10-10 | 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 | 2019-09-13 | 2019-10-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-13 | 2019-10-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-13 | 2019-10-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-13 | 2019-10-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-13 | 2019-10-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-13 | 2019-10-10 | 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 | 2019-09-13 | 2019-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-13 | 2019-10-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-28 | 2018-10-31 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-09-28 | 2018-10-31 | 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 | 2018-09-28 | 2018-10-31 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-09-28 | 2018-10-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-09-28 | 2018-10-31 | 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 | 2018-09-28 | 2018-10-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-09-28 | 2018-10-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-09-28 | 2018-10-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-09-28 | 2018-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-28 | 2018-10-31 | 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 | 2018-09-28 | 2018-10-31 | 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 | 2018-09-28 | 2018-10-31 | 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 | 2018-09-28 | 2018-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-28 | 2018-10-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-28 | 2018-10-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-09-27 | 2018-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-27 | 2018-10-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-09-27 | 2018-10-30 | N |
