Deficiency Records for Blue Lake Post Acute
Updated as of March 01, 2020
This is not the most recent data for Blue Lake Post Acute. For the most recent information, click here.
A list of the most recent deficiencies for Blue Lake Post Acute. 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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-20 | 2019-10-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-03-01 | 2019-08-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-23 | 2019-06-16 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2019-05-23 | 2019-06-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-01 | 2019-06-16 | 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 | 2019-03-01 | 2019-06-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-25 | 2019-05-07 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-02-25 | 2019-05-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-02-25 | 2019-05-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-02-25 | 2019-05-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-25 | 2019-05-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-25 | 2019-05-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-01 | 2019-05-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-01 | 2019-05-07 | 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 | 2019-03-01 | 2019-05-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-01 | 2019-05-07 | 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 | 2019-03-01 | 2019-05-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-03-01 | 2019-05-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-01 | 2019-05-07 | 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 | 2019-03-01 | 2019-05-07 | N |
| Post nurse staffing information every day. | Health | 2019-03-01 | 2019-05-07 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-01 | 2019-05-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-01 | 2019-05-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-01 | 2019-05-07 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-03-01 | 2019-05-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-01 | 2019-05-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-14 | 2018-12-14 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-11 | 2018-10-19 | 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 | 2018-09-11 | 2018-10-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-09-11 | 2018-10-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-11 | 2018-10-19 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-05-03 | 2018-06-03 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-05-03 | 2018-06-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-05-03 | 2018-06-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-03 | 2018-06-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-03 | 2018-06-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-03 | 2018-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-03 | 2018-06-03 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2018-05-03 | 2018-06-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-03 | 2018-06-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-03 | 2018-06-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-03 | 2018-06-03 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-05-03 | 2018-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-03 | 2018-06-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-10-25 | 2017-12-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-10-26 | 2017-12-08 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-10-26 | 2017-12-08 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-10-26 | 2017-12-08 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-26 | 2017-12-08 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-10-26 | 2017-12-08 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-26 | 2017-12-08 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-26 | 2017-12-08 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-04-24 | 2017-05-24 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-24 | 2017-05-24 | Y |
