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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-09 | 2023-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-09 | 2023-08-23 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-10-28 | 2023-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-28 | 2023-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-28 | 2023-02-07 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-28 | 2022-12-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-28 | 2022-12-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-28 | 2022-12-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-28 | 2022-12-21 | 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 | 2022-10-28 | 2022-12-13 | 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 | 2022-10-28 | 2022-12-13 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-28 | 2022-12-13 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-10-28 | 2022-12-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-28 | 2022-12-08 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-28 | 2022-12-08 | N |
| Post nurse staffing information every day. | Health | 2022-10-28 | 2022-12-08 | 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 | 2022-10-28 | 2022-12-08 | 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 | 2022-10-28 | 2022-12-08 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-28 | 2022-12-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-28 | 2022-12-08 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-28 | 2022-12-08 | Y |
| 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 | 2022-10-28 | 2022-12-08 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-10-28 | 2022-12-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-12-08 | Y |
| 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 | 2022-10-28 | 2022-12-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-28 | 2022-12-08 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-10-28 | 2022-12-08 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-10-28 | 2022-12-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-28 | 2022-12-08 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-28 | 2022-12-08 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-28 | 2022-12-08 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-10-28 | 2022-12-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-17 | 2022-03-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-17 | 2022-03-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-17 | 2022-03-24 | 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 |
| 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 |
| 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 |
| 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 |
| 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 |
| 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 |
