A list of the most recent deficiencies for Solaris Healthcare Lake Zephyr. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-09-18 | 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 | 2022-08-18 | 2022-09-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-18 | 2022-09-18 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-18 | 2022-09-18 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-18 | 2022-09-18 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-15 | 2022-09-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-15 | 2022-09-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-15 | 2022-09-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-15 | 2022-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-02 | 2021-05-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-02 | 2021-05-02 | 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 | 2021-04-02 | 2021-05-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-02 | 2021-05-02 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-04-02 | 2021-05-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-01 | 2021-05-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-01 | 2021-04-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-01 | 2021-04-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-01 | 2021-04-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-01 | 2021-04-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-22 | 2019-03-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-22 | 2019-03-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-02-22 | 2019-03-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-19 | 2019-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-19 | 2019-03-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-19 | 2019-03-22 | N |
