A list of the most recent deficiencies for Canterbury On The Lake. 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 | 2023-09-07 | 2023-10-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-20 | 2023-07-27 | 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 | 2023-07-20 | 2023-07-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-20 | 2023-07-27 | 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 | 2023-07-20 | 2023-07-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-20 | 2023-07-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-20 | 2023-07-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-07-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-20 | 2023-07-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-20 | 2023-07-27 | 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 | 2023-07-20 | 2023-07-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-20 | 2023-07-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-20 | 2023-07-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-07-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-07-07 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-16 | 2023-04-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-03-24 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-03-16 | 2023-03-24 | Y |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-15 | 2023-03-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-13 | 2022-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-13 | 2022-09-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-23 | 2022-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-23 | 2022-09-20 | Y |
| 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 | 2022-06-23 | 2022-09-20 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-06-23 | 2022-07-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-23 | 2022-07-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-23 | 2022-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-23 | 2022-07-25 | 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 | 2022-06-23 | 2022-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-23 | 2022-07-25 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-06-23 | 2022-07-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-06-23 | 2022-07-25 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-06-23 | 2022-07-25 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-06-23 | 2022-07-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-23 | 2022-07-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-23 | 2022-07-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-23 | 2022-07-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-23 | 2022-07-25 | 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 | 2022-06-23 | 2022-07-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-23 | 2022-07-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-23 | 2022-07-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-07-25 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-23 | 2022-07-25 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-23 | 2022-07-25 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-22 | 2022-07-25 | 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 | 2022-06-22 | 2022-07-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-22 | 2022-07-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-28 | 2021-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-10-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-18 | 2021-06-14 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-03-18 | 2021-04-26 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-03-18 | 2021-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-18 | 2021-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-18 | 2021-04-26 | 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 | 2021-03-18 | 2021-04-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-03-18 | 2021-04-26 | 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 | 2021-03-18 | 2021-04-26 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-03-18 | 2021-04-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-18 | 2021-04-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-18 | 2021-04-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-18 | 2021-04-26 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-18 | 2021-04-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-18 | 2021-03-30 | N |
