Deficiency Records for Charming Lakes Rehab
Updated as of February 01, 2019
This is not the most recent data for Charming Lakes Rehab. For the most recent information, click here.
A list of the most recent deficiencies for Charming Lakes Rehab. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-05 | 2018-12-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-05 | 2018-12-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-05 | 2018-12-28 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-10-05 | 2018-12-28 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-10-05 | 2018-10-29 | 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 | 2018-10-05 | 2018-10-29 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2018-10-05 | 2018-10-29 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-10-05 | 2018-10-29 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-10-05 | 2018-10-29 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-06-21 | 2018-07-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-06-21 | 2018-07-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-21 | 2018-07-25 | N |
| Be properly staffed | Fire Safety | 2018-06-21 | 2018-07-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-22 | 2018-07-25 | 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 | 2018-06-22 | 2018-07-25 | N |
| Respond appropriately to all alleged violations. | Health | 2018-06-22 | 2018-07-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-06-22 | 2018-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-22 | 2018-07-25 | 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 | 2018-06-22 | 2018-07-25 | 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 | 2018-06-22 | 2018-07-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-06-22 | 2018-07-25 | 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 ne | Health | 2018-06-22 | 2018-07-25 | 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 | 2018-06-22 | 2018-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-22 | 2018-07-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-22 | 2018-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-22 | 2018-07-25 | N |
| Keep all essential equipment working safely. | Health | 2018-06-22 | 2018-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-26 | 2018-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-26 | 2018-02-23 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2017-06-23 | 2017-07-23 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-06-23 | 2017-07-23 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-23 | 2017-07-23 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-23 | 2017-07-23 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2017-06-23 | 2017-07-23 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-06-23 | 2017-07-23 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-05-03 | 2017-05-17 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-11 | 2017-02-06 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-01-11 | 2017-02-06 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-01-11 | 2017-02-06 | Y |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-01-11 | 2017-02-06 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-01-11 | 2017-02-06 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-09-09 | 2016-09-27 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-09-09 | 2016-09-27 | Y |
| At least two compartments on every floor to protect residents from smoke. | Fire Safety | 2016-02-24 | 2016-03-27 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-02-24 | 2016-03-27 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-02-24 | 2016-03-27 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-02-24 | 2016-03-27 | N |
| An adequate water supply for the sprinkler system. | Fire Safety | 2016-02-24 | 2016-03-27 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2016-02-27 | 2016-03-27 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-02-27 | 2016-03-27 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2016-02-27 | 2016-03-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-02-27 | 2016-03-27 | N |
| Provide housekeeping and maintenance services. | Health | 2016-02-27 | 2016-03-27 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-02-27 | 2016-03-27 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-02-27 | 2016-03-27 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-02-27 | 2016-03-27 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-02-27 | 2016-03-27 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-02-27 | 2016-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-02-27 | 2016-03-27 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-02-27 | 2016-03-27 | 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 | 2016-02-27 | 2016-03-27 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-02-27 | 2016-03-27 | N |
| Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2016-02-27 | 2016-03-27 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2016-02-27 | 2016-03-27 | N |
| Provide or obtain dental services for each resident. | Health | 2016-02-27 | 2016-03-27 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-02-27 | 2016-03-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-02-27 | 2016-03-27 | N |
| Keep all essential equipment working safely. | Health | 2016-02-27 | 2016-03-27 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-02-27 | 2016-03-27 | N |
