A list of the most recent deficiencies for Ecumen Lakeshore. 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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-08 | 2023-10-09 | 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 | 2023-09-08 | 2023-10-09 | 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 | 2023-09-08 | 2023-10-09 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-09-08 | 2023-10-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-08 | 2023-10-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-05 | 2023-10-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-05 | 2023-10-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-05 | 2023-10-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-05 | 2023-09-30 | 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 | 2023-09-05 | 2023-09-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-05 | 2023-09-25 | N |
| Post nurse staffing information every day. | Health | 2022-11-08 | 2022-12-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-07-09 | 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 | 2022-05-25 | 2022-07-09 | 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 | 2022-05-25 | 2022-07-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-25 | 2022-07-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-25 | 2022-07-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-25 | 2022-07-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-25 | 2022-07-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-07-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-25 | 2022-07-09 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-23 | 2022-07-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-23 | 2022-07-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-30 | 2021-09-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-30 | 2021-09-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-30 | 2021-09-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-15 | 2021-05-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-15 | 2021-05-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-04-15 | 2021-05-30 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-04-15 | 2021-05-30 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-13 | 2021-05-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-13 | 2021-05-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-13 | 2021-05-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-13 | 2021-05-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-13 | 2021-05-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-13 | 2021-05-07 | N |
