Deficiency Records for Holmes Lake Rehabilitation and Care Center
Updated as of February 01, 2023
This is not the most recent data for Holmes Lake Rehabilitation and Care Center. For the most recent information, click here.
A list of the most recent deficiencies for Holmes Lake Rehabilitation and 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-08 | 2022-12-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-08 | 2022-12-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-08 | 2022-12-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-08 | 2022-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-08 | 2022-12-31 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-08 | 2022-12-31 | 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 | 2022-11-08 | 2022-12-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-08 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-08 | 2022-12-31 | 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 | 2022-11-08 | 2022-12-31 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-08 | 2022-12-31 | 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 | 2022-11-08 | 2022-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-08 | 2022-12-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-27 | 2021-07-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-27 | 2021-07-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-05-27 | 2021-07-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-27 | 2021-07-08 | 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 | 2021-05-27 | 2021-07-08 | 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 | 2021-05-27 | 2021-07-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-27 | 2021-07-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-27 | 2021-07-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-27 | 2021-07-08 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-25 | 2021-06-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-25 | 2021-06-01 | 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 | 2021-05-25 | 2021-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-01 | 2020-10-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2020-10-01 | 2020-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-08 | 2020-10-23 | N |
| Meet other general requirements. | Fire Safety | 2019-08-20 | 2019-10-07 | 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 | 2019-08-20 | 2019-10-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-20 | 2019-10-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-08-20 | 2019-10-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-20 | 2019-10-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-20 | 2019-10-07 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-08-20 | 2019-10-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-22 | 2019-10-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-22 | 2019-10-04 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-08-22 | 2019-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-22 | 2019-10-04 | 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 | 2019-08-22 | 2019-10-04 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-22 | 2019-10-04 | 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 | 2019-08-22 | 2019-10-04 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-08-22 | 2019-10-04 | 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 | 2019-08-22 | 2019-10-04 | 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 | 2019-08-22 | 2019-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-22 | 2019-10-04 | N |
