Deficiency Records for Lakepointe Senior Care and Rehab Center, L L C
Updated as of March 01, 2024
A list of the most recent deficiencies for Lakepointe Senior Care and Rehab Center, L L C. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-28 | 2023-07-24 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-06-28 | 2023-07-24 | N |
| 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 | 2023-06-28 | 2023-07-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-28 | 2023-07-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-28 | 2023-07-24 | 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 | 2023-06-28 | 2023-07-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-28 | 2023-07-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-28 | 2023-07-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-28 | 2023-07-24 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-28 | 2023-07-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-28 | 2023-07-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-28 | 2023-07-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-28 | 2023-07-24 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-06-28 | 2023-07-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-22 | 2023-03-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-28 | 2023-01-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-28 | 2023-01-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-28 | 2023-01-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-28 | 2023-01-24 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-10 | 2022-07-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-17 | 2022-06-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-17 | 2022-06-09 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-17 | 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 | 2022-05-17 | 2022-06-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-17 | 2022-06-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-17 | 2022-06-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-17 | 2022-06-09 | 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 | 2022-05-17 | 2022-06-09 | 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 | 2022-05-17 | 2022-06-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-17 | 2022-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-17 | 2022-06-09 | N |
| Report COVID19 data to residents and families. | Health | 2022-05-17 | 2022-06-09 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-17 | 2022-06-09 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-17 | 2022-06-09 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2022-05-17 | 2022-06-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-17 | 2022-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-17 | 2022-06-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-17 | 2022-06-09 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-05-17 | 2022-06-09 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-17 | 2022-06-09 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-05-17 | 2022-06-09 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-10 | 2022-06-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-10 | 2022-06-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-10 | 2022-06-09 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-02-23 | 2022-03-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-23 | 2022-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-23 | 2022-03-17 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-11-01 | 2021-11-26 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-11-01 | 2021-11-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-01 | 2021-11-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-09 | 2021-04-02 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-17 | 2019-10-21 | 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 | 2019-09-17 | 2019-10-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-17 | 2019-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-18 | 2019-10-14 | N |
