Deficiency Records for Lake Mariam Health and Rehabilitation Center
Updated as of April 01, 2024
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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-02-25 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-01-25 | 2024-02-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-25 | 2024-02-25 | 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 | 2024-01-25 | 2024-02-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-25 | 2024-02-25 | N |
| Provide appropriate foot care. | Health | 2024-01-25 | 2024-02-25 | 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 | 2024-01-25 | 2024-02-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-25 | 2024-02-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-25 | 2024-02-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-25 | 2024-02-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-01-25 | 2024-02-25 | N |
| Post nurse staffing information every day. | Health | 2024-01-25 | 2024-02-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-25 | 2024-02-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-25 | 2024-02-25 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-01-25 | 2024-02-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-25 | 2024-02-25 | N |
| Dispose of garbage and refuse properly. | Health | 2024-01-25 | 2024-02-25 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-01-25 | 2024-02-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-25 | 2024-02-25 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-01-25 | 2024-02-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-25 | 2024-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-25 | 2024-02-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-25 | 2024-02-25 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-01-25 | 2024-02-25 | N |
| Provide a bathroom in or located near each resident?s room. | Health | 2024-01-25 | 2024-02-25 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2024-01-25 | 2024-02-25 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-01-25 | 2024-02-25 | N |
| Have policies on smoking. | Health | 2024-01-25 | 2024-02-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-25 | 2024-02-25 | Y |
| 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 | 2024-01-25 | 2024-02-25 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-01-25 | 2024-02-25 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-01-25 | 2024-02-25 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-25 | 2024-02-25 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-25 | 2024-02-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-01-25 | 2024-02-21 | 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 | 2023-08-18 | 2023-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-18 | 2023-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-18 | 2023-09-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-18 | 2023-09-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-06 | 2022-11-06 | 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 | 2022-10-06 | 2022-11-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-15 | 2022-07-15 | Y |
| Report COVID19 data to residents and families. | Health | 2022-06-15 | 2022-07-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-08 | 2021-12-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-08 | 2021-12-30 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-10-08 | 2021-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-08 | 2021-11-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-08 | 2021-11-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-08 | 2021-11-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-08 | 2021-11-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-04 | 2021-11-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-15 | 2021-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-15 | 2021-07-15 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-11-15 | 2019-12-15 | 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 | 2019-11-15 | 2019-12-15 | 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 | 2019-11-15 | 2019-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-15 | 2019-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-15 | 2019-12-15 | 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 | 2019-11-15 | 2019-12-15 | 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 | 2019-11-15 | 2019-12-15 | 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 | 2019-11-15 | 2019-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-15 | 2019-12-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-11-15 | 2019-12-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-15 | 2019-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-15 | 2019-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-15 | 2019-12-15 | N |
