Deficiency Records for Lakeside Manor Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Lakeside Manor 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-09 | 2023-10-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-09 | 2023-10-25 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-28 | 2023-07-12 | 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 | 2023-06-28 | 2023-07-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-28 | 2023-07-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-28 | 2023-07-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-10 | 2023-06-16 | 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 | 2023-05-10 | 2023-06-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-10 | 2023-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-10 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-10 | 2023-06-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-10 | 2023-06-16 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-05-10 | 2023-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-10 | 2023-06-16 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-08 | 2023-06-16 | 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 | 2023-05-08 | 2023-06-16 | 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 | 2023-05-08 | 2023-06-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-05-08 | 2023-06-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-05 | 2023-04-27 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-04-05 | 2023-04-27 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-05 | 2023-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-04-27 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-04 | 2022-11-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-04 | 2022-11-08 | Y |
| 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 | 2022-04-05 | 2022-09-07 | 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 | 2022-04-05 | 2022-09-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-05 | 2022-09-07 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-05 | 2022-09-07 | 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 | 2022-04-05 | 2022-09-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-05 | 2022-09-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-05 | 2022-09-07 | 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 | 2022-04-05 | 2022-09-07 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-08-19 | 2022-08-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-19 | 2022-08-31 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-08-19 | 2022-08-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-19 | 2022-08-31 | Y |
| 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 | 2022-08-19 | 2022-08-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-19 | 2022-08-31 | 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 | 2022-08-19 | 2022-08-31 | 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 | 2022-08-19 | 2022-08-31 | 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 | 2022-08-19 | 2022-08-31 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-19 | 2022-08-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-19 | 2022-08-31 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-08-19 | 2022-08-31 | Y |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-03-30 | 2022-07-13 | 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 | 2022-03-30 | 2022-07-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-30 | 2022-07-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-30 | 2022-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-30 | 2022-07-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Develop a communication plan. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-30 | 2022-05-20 | 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 | 2022-03-30 | 2022-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-30 | 2022-05-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-05 | 2022-05-15 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-04-05 | 2022-05-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-05 | 2022-05-15 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-04-05 | 2022-05-15 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-04-05 | 2022-05-15 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-04-05 | 2022-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-05 | 2022-05-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-04-05 | 2022-05-15 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-04-05 | 2022-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-05 | 2022-05-15 | 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 | 2022-04-05 | 2022-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-05 | 2022-05-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-05 | 2022-05-15 | 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 | 2022-04-05 | 2022-05-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-05 | 2022-05-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-05 | 2022-05-15 | N |
| 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 | 2022-04-05 | 2022-05-15 | N |
| 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 | 2022-04-05 | 2022-05-15 | 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 | 2022-04-05 | 2022-05-15 | N |
| Post nurse staffing information every day. | Health | 2022-04-05 | 2022-05-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-05 | 2022-05-15 | 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 | 2022-04-05 | 2022-05-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-05 | 2022-05-15 | 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 | 2022-04-05 | 2022-05-15 | 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 | 2022-04-05 | 2022-05-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-05 | 2022-05-15 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-04-05 | 2022-05-15 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-04-05 | 2022-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-05 | 2022-05-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-05 | 2022-05-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-04-05 | 2022-05-15 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2022-04-05 | 2022-05-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-05 | 2022-05-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-04-05 | 2022-05-15 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-04-05 | 2022-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-05 | 2022-05-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-05 | 2022-05-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-05 | 2022-05-15 | 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 | 2022-04-05 | 2022-05-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-05 | 2022-05-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-21 | 2022-02-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-21 | 2022-02-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-21 | 2022-02-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-21 | 2022-02-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-23 | 2022-02-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-03 | 2022-02-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-23 | 2021-12-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-23 | 2021-12-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-03 | 2021-12-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-03 | 2021-12-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-12-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-19 | 2021-09-24 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-08-19 | 2021-09-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-19 | 2021-09-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-19 | 2021-09-24 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-08-19 | 2021-09-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-19 | 2021-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-09-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-19 | 2021-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-09 | 2021-07-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-09 | 2021-07-09 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-06-09 | 2021-07-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-09 | 2021-07-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-09 | 2021-07-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-05 | 2021-05-31 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2019-09-25 | 2020-03-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-25 | 2019-10-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-25 | 2019-10-20 | 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 | 2019-09-25 | 2019-10-20 | 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 | 2019-09-25 | 2019-10-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-25 | 2019-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-25 | 2019-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-25 | 2019-10-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-25 | 2019-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-25 | 2019-10-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-02 | 2019-10-18 | 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 | 2019-10-02 | 2019-10-18 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-02 | 2019-10-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-02 | 2019-10-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-02 | 2019-10-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-02 | 2019-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-02 | 2019-10-18 | 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 | 2019-10-02 | 2019-10-18 | 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 | 2019-10-02 | 2019-10-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-02 | 2019-10-18 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-02 | 2019-10-18 | 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 | 2019-10-02 | 2019-10-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-02 | 2019-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-02 | 2019-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-02 | 2019-10-18 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-10-02 | 2019-10-18 | N |
