A list of the most recent deficiencies for Lake Regional Health Systems. 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? |
|---|---|---|---|---|
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-08-23 | 2022-09-16 | 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 | 2022-08-23 | 2022-09-16 | N |
| Post nurse staffing information every day. | Health | 2022-08-23 | 2022-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-23 | 2022-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-23 | 2022-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-23 | 2022-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-23 | 2022-09-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-23 | 2022-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-14 | 2019-12-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-14 | 2019-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-14 | 2019-12-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-14 | 2019-12-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-14 | 2019-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-17 | 2018-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-17 | 2018-11-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-10-17 | 2018-11-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-17 | 2018-11-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-10-17 | 2018-11-07 | 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 | 2018-10-17 | 2018-11-07 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-10-17 | 2018-11-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-17 | 2018-10-30 | N |
