Deficiency Records for The Estates of Hidden Lake
Updated as of January 01, 2021
This is not the most recent data for The Estates of Hidden Lake. For the most recent information, click here.
A list of the most recent deficiencies for The Estates of Hidden Lake. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-26 | 2020-03-13 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-27 | 2019-11-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-27 | 2019-11-14 | 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 | 2019-08-27 | 2019-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-27 | 2019-11-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-27 | 2019-10-11 | 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 | 2019-08-27 | 2019-10-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-27 | 2019-10-11 | 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 | 2019-08-27 | 2019-10-11 | 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 | 2019-08-27 | 2019-10-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-27 | 2019-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-27 | 2019-10-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-27 | 2019-10-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-27 | 2019-10-11 | 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 | 2019-08-27 | 2019-10-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-08-27 | 2019-10-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-27 | 2019-10-11 | 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 | 2019-08-27 | 2019-10-11 | 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 | 2019-08-27 | 2019-10-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-08-27 | 2019-10-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-08-27 | 2019-10-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-27 | 2019-10-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-10-09 | 2019-10-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-26 | 2019-10-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-29 | 2019-07-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-02 | 2019-06-26 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-20 | 2019-01-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-20 | 2019-01-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-11-20 | 2019-01-03 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-11-20 | 2019-01-03 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-11-20 | 2019-01-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-20 | 2019-01-03 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2018-11-20 | 2019-01-03 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-11-20 | 2019-01-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-20 | 2019-01-03 | 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 | 2018-11-20 | 2019-01-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-20 | 2019-01-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-20 | 2019-01-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-20 | 2019-01-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-11-20 | 2019-01-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-11-20 | 2019-01-03 | N |
| Post nurse staffing information every day. | Health | 2018-11-20 | 2019-01-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-20 | 2019-01-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-20 | 2019-01-03 | 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 | 2018-11-20 | 2019-01-03 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-11-20 | 2019-01-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-20 | 2019-01-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-11-20 | 2019-01-03 | 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 | 2018-01-19 | 2018-02-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-01-19 | 2018-02-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-01-19 | 2018-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-19 | 2018-02-26 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-01-19 | 2018-02-26 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2018-01-19 | 2018-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-19 | 2018-02-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-19 | 2018-02-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-12-28 | Not Fixed | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2020-12-28 | Not Fixed | N |
| Perform COVID19 testing on residents and staff. | Health | 2020-12-28 | Not Fixed | N |
