Deficiency Records for Lake Woods Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Lake Woods Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-12 | 2023-10-13 | 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 | 2023-09-12 | 2023-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-12 | 2023-06-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-27 | 2023-05-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-27 | 2023-05-23 | 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 | 2023-04-27 | 2023-05-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-27 | 2023-05-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-27 | 2023-05-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-27 | 2023-05-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-27 | 2023-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-02 | 2022-06-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-03 | 2022-04-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-03 | 2022-04-13 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-03-03 | 2022-04-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-03 | 2022-04-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-03 | 2022-04-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-03 | 2022-04-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-03 | 2022-04-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-03 | 2022-04-13 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-02 | 2022-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-02 | 2022-03-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-05 | 2021-09-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-05 | 2021-09-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-05 | 2021-09-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-05 | 2021-09-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-10-29 | 2020-12-15 | 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 | 2020-10-29 | 2020-12-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-29 | 2020-12-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-10-29 | 2020-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-29 | 2020-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-29 | 2020-12-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-10 | 2020-04-15 | N |
