A list of the most recent deficiencies for Hidden Lake Care 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? |
|---|---|---|---|---|
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-18 | 2023-10-18 | 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 | 2022-11-16 | 2023-02-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-16 | 2023-02-17 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-16 | 2023-02-17 | 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 | 2022-11-16 | 2023-02-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-16 | 2023-02-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-11-16 | 2023-02-17 | 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 | 2022-11-16 | 2023-01-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-16 | 2023-01-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-12 | 2023-01-03 | 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 | 2022-11-16 | 2022-12-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-16 | 2022-12-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-16 | 2022-12-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-16 | 2022-12-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-16 | 2022-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-16 | 2022-12-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-16 | 2022-12-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-16 | 2022-12-31 | N |
| Post nurse staffing information every day. | Health | 2022-11-16 | 2022-12-31 | 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 | 2022-11-16 | 2022-12-31 | N |
| Dispose of garbage and refuse properly. | Health | 2022-11-16 | 2022-12-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-16 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-16 | 2022-12-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-16 | 2022-12-31 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-11-16 | 2022-12-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-16 | 2022-12-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-16 | 2022-12-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-16 | 2022-12-31 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-16 | 2022-12-31 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-16 | 2022-12-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-20 | 2022-06-22 | 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 | 2022-05-20 | 2022-06-22 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-05-03 | 2021-06-17 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-03-02 | 2021-03-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-02 | 2021-03-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-02 | 2021-03-09 | 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 | 2020-02-27 | 2020-03-31 | 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 | 2020-02-27 | 2020-03-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-27 | 2020-03-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-27 | 2020-03-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-02-27 | 2020-03-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-27 | 2020-03-31 | 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 | 2020-02-27 | 2020-03-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-27 | 2020-03-31 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2020-02-27 | 2020-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-27 | 2020-03-31 | 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 | 2020-02-27 | 2020-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-27 | 2020-03-31 | 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 | 2020-02-27 | 2020-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-27 | 2020-03-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-27 | 2020-03-31 | 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 | 2020-02-27 | 2020-03-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-27 | 2020-03-31 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2020-02-27 | 2020-03-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-02-27 | 2020-03-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-27 | 2020-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-27 | 2020-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-27 | 2020-03-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-27 | 2020-03-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-22 | 2019-06-20 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-03-22 | 2019-05-01 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-03-22 | 2019-05-01 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-03-22 | 2019-05-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-03-22 | 2019-05-01 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-03-22 | 2019-05-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-22 | 2019-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-22 | 2019-05-01 | N |
| Post nurse staffing information every day. | Health | 2019-03-22 | 2019-05-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-03-22 | 2019-05-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-22 | 2019-05-01 | 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 | 2019-03-22 | 2019-05-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-03-22 | 2019-05-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-22 | 2019-05-01 | 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 | 2019-03-22 | 2019-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-22 | 2019-05-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-03-22 | 2019-05-01 | 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 | 2019-03-22 | 2019-05-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-22 | 2019-05-01 | N |
