Deficiency Records for Lake Mariam Health and Rehabilitation Center
Updated as of February 01, 2018
This is not the most recent data for Lake Mariam Health and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Lake Mariam Health and Rehabilitation 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-08-23 | 2017-09-25 | 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 | 2017-08-23 | 2017-09-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-08-23 | 2017-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-23 | 2017-09-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-08-23 | 2017-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-08-23 | 2017-09-25 | N |
| Provide housekeeping and maintenance services. | Health | 2017-08-25 | 2017-09-25 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-08-25 | 2017-09-25 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-25 | 2017-09-25 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-08-25 | 2017-09-25 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-08-25 | 2017-09-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-01-11 | 2017-02-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-01-11 | 2017-02-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-01-11 | 2017-02-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-01-13 | 2017-02-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-01-13 | 2017-02-13 | N |
| Let residents voice a complaint or grievance without being treated differently or badly. | Health | 2017-01-13 | 2017-02-13 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-01-13 | 2017-02-13 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-01-13 | 2017-02-13 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-01-13 | 2017-02-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-01-13 | 2017-02-13 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-01-13 | 2017-02-13 | N |
| Provide housekeeping and maintenance services. | Health | 2017-01-13 | 2017-02-13 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-01-13 | 2017-02-13 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-01-13 | 2017-02-13 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-01-13 | 2017-02-13 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-01-13 | 2017-02-13 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-01-13 | 2017-02-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-13 | 2017-02-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-01-13 | 2017-02-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-01-13 | 2017-02-13 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-09-15 | 2015-10-17 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2015-09-15 | 2015-10-17 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2015-09-15 | 2015-10-17 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-09-15 | 2015-10-17 | N |
| Properly protected cooking facilities. | Fire Safety | 2015-09-15 | 2015-10-17 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2015-09-15 | 2015-10-17 | N |
| Proper construction of ducts through walls designed to prevent smoke passage. | Fire Safety | 2015-09-15 | 2015-10-17 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-09-15 | 2015-10-17 | N |
| Provide care for each resident in a way that maintains or improves their quality of life. | Health | 2015-10-05 | 2015-10-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2015-09-17 | 2015-10-17 | N |
| Maintain comfortable and safe temperature levels. | Health | 2015-09-17 | 2015-10-17 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2015-09-17 | 2015-10-17 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-09-17 | 2015-10-17 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2015-09-17 | 2015-10-17 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-09-17 | 2015-10-17 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2015-09-17 | 2015-10-17 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2015-09-17 | 2015-10-17 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-09-17 | 2015-10-17 | N |
| Provide or obtain dental services for each resident. | Health | 2015-09-17 | 2015-10-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2015-09-17 | 2015-10-17 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2015-09-17 | 2015-10-17 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-09-17 | 2015-10-17 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-03-24 | 2015-04-24 | Y |
