A list of the most recent deficiencies for Lakeview Gardens. 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 each resident receives an accurate assessment. | Health | 2022-08-12 | 2022-09-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-08-12 | 2022-09-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-12 | 2022-09-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-12 | 2022-09-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-12 | 2022-09-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-12 | 2022-09-08 | 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 | 2022-08-12 | 2022-09-08 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-12 | 2022-09-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-12 | 2022-09-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-09-08 | Y |
| 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 | 2022-08-12 | 2022-09-08 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-10 | 2022-09-08 | N |
| 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 | 2021-11-06 | 2021-12-16 | 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 | 2021-11-06 | 2021-12-16 | N |
| Provide activities to meet all resident's needs. | Health | 2021-11-06 | 2021-12-16 | 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 | 2021-11-06 | 2021-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-06 | 2021-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-03 | 2021-12-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-03 | 2021-12-16 | 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 | 2018-07-20 | 2018-11-02 | 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 | 2018-07-20 | 2018-10-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-18 | 2018-09-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-07-20 | 2018-09-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-20 | 2018-09-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-07-20 | 2018-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-20 | 2018-09-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-20 | 2018-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-20 | 2018-09-07 | 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 | 2018-07-20 | 2018-09-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-07-20 | 2018-09-07 | 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 | 2018-07-20 | 2018-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-20 | 2018-09-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-20 | 2018-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-20 | 2018-09-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-07-20 | 2018-09-07 | N |
| 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 | 2018-07-20 | 2018-09-07 | N |
