A list of the most recent deficiencies for The Club at Lake Gibson. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-02 | 2023-02-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-02 | 2023-02-22 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-19 | 2023-01-05 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-11-29 | 2023-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-29 | 2023-01-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-29 | 2023-01-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-29 | 2023-01-03 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-12-02 | 2022-12-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-02 | 2022-12-31 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-02 | 2022-12-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-02 | 2022-12-31 | 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 | 2022-12-02 | 2022-12-31 | N |
| Provide or obtain dental services for each resident. | Health | 2022-12-02 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-02 | 2022-12-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-02 | 2022-12-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-02 | 2022-12-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-02 | 2022-12-31 | 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 | 2022-12-02 | 2022-12-31 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-12-02 | 2022-12-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-02 | 2022-12-31 | Y |