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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-18 | 2024-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-18 | 2024-02-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-18 | 2024-02-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-18 | 2024-02-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-18 | 2024-02-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-18 | 2024-02-07 | 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 | 2024-01-18 | 2024-02-07 | N |
| 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 |
