A list of the most recent deficiencies for The Lakeland 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-01 | 2024-04-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-01 | 2024-02-23 | 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 | 2024-02-01 | 2024-02-23 | 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 | 2024-02-01 | 2024-02-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-01 | 2024-02-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-31 | 2024-02-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-31 | 2024-02-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-31 | 2024-02-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-31 | 2024-02-19 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-31 | 2024-02-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-31 | 2024-02-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-06 | 2023-07-27 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-06 | 2023-07-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-31 | 2023-05-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-31 | 2023-05-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-31 | 2023-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-31 | 2023-04-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-31 | 2023-04-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-31 | 2023-04-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-31 | 2023-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-31 | 2023-04-26 | 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 | 2023-03-31 | 2023-04-26 | 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 | 2023-03-31 | 2023-04-26 | 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 | 2023-03-31 | 2023-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-31 | 2023-04-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-31 | 2023-04-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-31 | 2023-04-26 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-31 | 2023-04-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-31 | 2023-04-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-31 | 2023-04-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-31 | 2023-04-26 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-31 | 2023-04-26 | 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 | 2023-03-31 | 2023-04-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-31 | 2023-04-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-31 | 2023-04-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-31 | 2023-04-26 | 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 | 2023-03-31 | 2023-04-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-31 | 2023-04-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-31 | 2023-04-26 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-03-31 | 2023-04-26 | Y |
| 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 | 2023-03-29 | 2023-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-14 | 2022-11-08 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-14 | 2022-11-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-14 | 2022-10-11 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-14 | 2022-10-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-14 | 2022-10-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-14 | 2022-10-11 | 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 | 2022-09-14 | 2022-10-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-14 | 2022-10-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-14 | 2022-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-14 | 2022-10-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-14 | 2022-10-11 | 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 | 2022-09-14 | 2022-10-11 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-09-14 | 2022-10-11 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-03-30 | 2022-04-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-03-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-02 | 2022-03-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-02 | 2022-03-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-02 | 2022-03-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-02-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-26 | 2022-02-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-01-26 | 2022-02-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-26 | 2022-02-11 | 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 | 2022-01-26 | 2022-02-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-26 | 2022-02-11 | 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 | 2022-01-26 | 2022-02-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-26 | 2022-02-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-26 | 2022-02-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-26 | 2022-02-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-01-26 | 2022-02-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-26 | 2022-02-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-01-26 | 2022-02-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-26 | 2022-02-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-26 | 2022-02-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-02 | 2021-12-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-23 | 2021-10-12 | Y |
