A list of the most recent deficiencies for Lakepoint El Dorado, LLC. 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? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-21 | 2023-03-23 | 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 | 2023-03-21 | 2023-03-23 | 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 | 2023-03-21 | 2023-03-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-03-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-21 | 2023-03-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-03-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-03-23 | 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 | 2023-02-16 | 2023-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-03 | Y |
| 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 | 2023-02-16 | 2023-03-03 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-16 | 2023-03-03 | Y |
| 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 | 2023-02-16 | 2023-03-03 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-16 | 2023-03-03 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-07 | 2022-07-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-26 | 2022-05-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-26 | 2022-02-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-26 | 2022-02-25 | 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 | 2022-01-26 | 2022-02-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-09-22 | 2021-10-08 | 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 | 2021-09-22 | 2021-10-08 | 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 | 2021-09-22 | 2021-10-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-22 | 2021-10-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-17 | 2021-09-01 | 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 | 2021-08-17 | 2021-09-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-17 | 2021-09-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-17 | 2021-09-01 | N |
| 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 | 2019-12-12 | 2020-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-12 | 2020-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-12 | 2020-01-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-12 | 2020-01-10 | 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 | 2019-12-12 | 2020-01-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-12 | 2020-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-12 | 2020-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2020-01-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-12-12 | 2020-01-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-12 | 2020-01-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-22 | 2019-11-21 | N |
