Deficiency Records for Eagle Lake Nursing and Rehab Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Eagle Lake Nursing and Rehab Care 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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-02 | 2023-12-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-12-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-02 | 2023-12-20 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-02 | 2023-12-20 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-02 | 2023-12-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-02 | 2023-12-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-02 | 2023-12-20 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-07 | 2023-09-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-07 | 2023-09-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-07 | 2023-09-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-07 | 2023-09-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-24 | 2023-03-26 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-24 | 2023-03-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-24 | 2023-03-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-24 | 2023-03-26 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-24 | 2023-03-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-24 | 2023-03-26 | Y |
| 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 | 2022-09-08 | 2022-10-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-08 | 2022-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-08 | 2022-10-08 | 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 | 2022-09-08 | 2022-10-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-08 | 2022-10-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-08 | 2022-10-08 | N |
| Meet other general requirements. | Fire Safety | 2022-09-07 | 2022-10-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-07 | 2022-10-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-05 | 2021-08-24 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-08-05 | 2021-08-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-05 | 2021-08-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-18 | 2021-07-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-11 | 2021-07-10 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-06-11 | 2021-07-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-11 | 2021-07-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-11 | 2021-07-10 | Y |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-03-18 | 2021-07-10 | 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 | 2021-03-18 | 2021-04-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-03-18 | 2021-04-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-18 | 2021-04-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-18 | 2021-04-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-18 | 2021-04-18 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-18 | 2021-04-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-18 | 2021-04-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-18 | 2021-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-18 | 2021-04-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-18 | 2021-04-18 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-03-18 | 2021-04-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-18 | 2021-04-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-07-18 | 2019-08-18 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-18 | 2019-08-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-18 | 2019-08-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-18 | 2019-08-18 | 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 | 2019-07-18 | 2019-08-18 | 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 | 2019-07-18 | 2019-08-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-18 | 2019-08-18 | 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 | 2019-07-18 | 2019-08-18 | 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 | 2019-07-18 | 2019-08-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-18 | 2019-08-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-17 | 2019-08-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-07-17 | 2019-08-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-17 | 2019-08-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-07-17 | 2019-08-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-17 | 2019-08-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-17 | 2019-08-18 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-07-17 | 2019-08-18 | N |
