A list of the most recent deficiencies for Thrive of Lake County. 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 | 2023-12-23 | 2023-12-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-23 | 2023-12-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-20 | 2023-11-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-20 | 2023-11-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-04 | 2023-10-11 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-03-29 | 2023-07-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-17 | 2023-07-25 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-17 | 2023-07-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-06 | 2023-06-14 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-03-29 | 2023-05-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-29 | 2023-05-05 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-29 | 2023-05-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-26 | 2023-05-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-10 | 2023-04-19 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-29 | 2023-04-15 | 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 | 2023-03-29 | 2023-04-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-29 | 2023-04-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-08 | 2023-03-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-08 | 2023-03-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-08 | 2023-03-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-08 | 2023-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-08 | 2023-03-17 | 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 | 2023-03-08 | 2023-03-17 | 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 | 2023-03-08 | 2023-03-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-08 | 2023-03-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-08 | 2023-03-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-08 | 2023-03-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-08 | 2023-03-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-08 | 2023-03-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-08 | 2023-03-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-12 | 2023-02-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-12 | 2023-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-12 | 2023-02-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-30 | 2023-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-30 | 2023-02-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-20 | 2023-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-20 | 2023-02-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-17 | 2023-02-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-17 | 2023-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-17 | 2023-02-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-09 | 2023-02-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-09 | 2023-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-09 | 2023-02-14 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-01 | 2023-02-08 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-01-30 | 2023-02-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-20 | 2023-02-02 | 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 | 2023-01-20 | 2023-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-20 | 2023-02-02 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-20 | 2023-02-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-20 | 2023-02-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-17 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-17 | 2023-01-27 | 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 | 2023-01-17 | 2023-01-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-17 | 2023-01-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-09 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-09 | 2023-01-27 | 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 | 2023-01-09 | 2023-01-27 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-20 | 2023-01-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-09 | 2023-01-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-09 | 2023-01-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-29 | 2023-01-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-06 | 2022-12-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-09 | 2022-12-03 | 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 | 2022-11-09 | 2022-12-03 | 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 | 2022-11-09 | 2022-12-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-25 | 2022-10-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-25 | 2022-10-31 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-03 | 2022-07-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-03 | 2022-07-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-06-03 | 2022-06-17 | 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 | 2022-06-03 | 2022-06-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-03 | 2022-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-03 | 2022-06-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-03 | 2022-06-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-03 | 2022-06-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-03 | 2022-06-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-25 | 2022-06-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-06-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-25 | 2022-06-09 | 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 | 2022-05-25 | 2022-06-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-25 | 2022-06-09 | 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 | 2022-05-25 | 2022-06-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-25 | 2022-06-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-16 | 2022-05-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-09 | 2022-03-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-09 | 2022-03-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-09 | 2022-03-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-25 | 2022-02-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-29 | 2021-12-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-03 | 2021-08-13 | 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 | 2021-07-27 | 2021-08-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-27 | 2021-08-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-30 | 2021-07-15 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-30 | 2021-07-15 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-28 | 2021-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-13 | 2021-05-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-05-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-23 | 2021-05-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-05-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-28 | 2021-05-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-28 | 2021-05-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-28 | 2021-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-28 | 2021-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-05-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-28 | 2021-05-18 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-23 | 2021-04-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-01 | 2021-03-22 | 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 | 2021-03-01 | 2021-03-22 | Y |
