Deficiency Records for Charming Lakes Rehab
Updated as of May 01, 2021
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? |
---|---|---|---|---|
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-09-22 | 2020-10-16 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-09-22 | 2020-10-16 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-11 | 2019-11-05 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-11 | 2019-11-05 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-11 | 2019-11-05 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-11 | 2019-11-04 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-11 | 2019-11-04 | 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 | 2019-10-11 | 2019-11-04 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2019-04-10 | 2019-05-11 | N |
Conduct testing and exercise requirements. | Fire Safety | 2019-04-10 | 2019-05-11 | N |
Have exits that are accessible at all times. | Fire Safety | 2019-04-10 | 2019-05-11 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-11 | 2019-05-11 | N |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-11 | 2019-05-11 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-11 | 2019-05-11 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-11 | 2019-05-11 | 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 | 2019-04-11 | 2019-05-11 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-11 | 2019-05-11 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-11 | 2019-05-11 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-11 | 2019-05-11 | N |
Provide and implement an infection prevention and control program. | Health | 2019-04-11 | 2019-05-11 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-04-11 | 2019-05-11 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-11 | 2019-05-11 | Y |
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 | 2019-04-11 | 2019-05-11 | Y |
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 |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 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 necessary and PRN use is limited. | 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 |