A list of the most recent deficiencies for Indian Lake Rehabilitation 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-23 | 2023-11-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-23 | 2023-11-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-11 | 2023-09-13 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-11 | 2023-09-13 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-12-16 | 2022-01-14 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-14 | 2022-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-14 | 2022-01-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-14 | 2022-01-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-14 | 2022-01-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-14 | 2022-01-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-14 | 2022-01-14 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-09 | 2021-06-10 | 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 | 2019-05-02 | 2019-05-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-02 | 2019-05-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-02 | 2019-05-28 | 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 | 2019-05-02 | 2019-05-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-05-28 | 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 | 2019-05-02 | 2019-05-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-02 | 2019-05-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-02 | 2019-05-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-02 | 2019-05-28 | 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 | 2019-05-02 | 2019-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-02 | 2019-05-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-02 | 2019-05-28 | N |
| Keep all essential equipment working safely. | Health | 2019-05-02 | 2019-05-28 | N |
| Develop a communication plan. | Fire Safety | 2019-05-02 | 2019-05-28 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-02 | 2019-05-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-02 | 2019-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-02 | 2019-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-02 | 2019-05-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-05-02 | 2019-05-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-02 | 2019-05-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-05 | 2018-05-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-05 | 2018-05-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-05 | 2018-05-14 | 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 | 2018-04-05 | 2018-05-14 | 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 | 2018-04-05 | 2018-05-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-04-05 | 2018-05-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-04-05 | 2018-05-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-04-05 | 2018-05-14 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-04-05 | 2018-05-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-09 | 2018-05-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-09 | 2018-05-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-04-09 | 2018-05-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-04-09 | 2018-05-14 | N |
