Deficiency Records for Lake Pointe Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Lake Pointe Rehabilitation and Nursing 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? |
|---|---|---|---|---|
| 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 | 2023-11-08 | 2023-11-28 | N |
| Dispose of garbage and refuse properly. | Health | 2023-11-08 | 2023-11-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-08 | 2023-11-28 | Y |
| 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 | 2023-11-06 | 2023-11-28 | 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 | 2023-11-06 | 2023-11-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-06 | 2023-11-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-06 | 2023-11-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-06 | 2023-11-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-06 | 2023-11-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-06 | 2023-11-28 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-11-06 | 2023-11-22 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-07-13 | 2023-07-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-13 | 2023-07-14 | 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 | 2022-08-11 | 2022-08-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-03 | 2022-03-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-28 | 2021-11-04 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-10-28 | 2021-11-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-10-28 | 2021-11-04 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-10-28 | 2021-11-04 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-10-28 | 2021-11-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-28 | 2021-11-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-28 | 2021-11-04 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-10-28 | 2021-11-04 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-28 | 2021-11-04 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-10-28 | 2021-11-04 | Y |
| 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 | 2021-10-28 | 2021-11-04 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-26 | 2021-11-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-26 | 2021-11-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-26 | 2021-11-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-26 | 2021-11-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-26 | 2021-11-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-26 | 2021-11-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-26 | 2021-11-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-24 | 2021-03-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-24 | 2021-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-24 | 2021-03-26 | Y |
| 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 | 2021-03-24 | 2021-03-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-14 | 2019-03-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-14 | 2019-03-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-14 | 2019-03-22 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-14 | 2019-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-14 | 2019-03-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-14 | 2019-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-14 | 2019-03-22 | 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 | 2019-03-14 | 2019-03-22 | 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 | 2019-03-14 | 2019-03-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-03-12 | 2019-03-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-12 | 2019-03-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-12 | 2019-03-22 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-03-12 | 2019-03-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-12 | 2019-03-22 | N |
