Deficiency Records for Kadima Rehabilitation and Nursing at Lakeside
Updated as of March 01, 2024
A list of the most recent deficiencies for Kadima Rehabilitation and Nursing at Lakeside. 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? |
|---|---|---|---|---|
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-19 | 2024-01-26 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-19 | 2024-01-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-19 | 2024-01-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-19 | 2024-01-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-19 | 2024-01-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-19 | 2024-01-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-19 | 2024-01-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-19 | 2024-01-26 | 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 | 2023-12-07 | 2024-01-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-07 | 2024-01-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-07 | 2024-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-07 | 2024-01-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-07 | 2024-01-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-07 | 2024-01-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-07 | 2024-01-05 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-12-07 | 2024-01-05 | 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 | 2023-12-07 | 2024-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2024-01-05 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-12-07 | 2024-01-04 | 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 | 2023-09-08 | 2023-10-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-01-06 | 2023-05-23 | N |
| Provide or obtain dental services for each resident. | Health | 2023-01-06 | 2023-05-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-06 | 2023-05-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-06 | 2023-05-23 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-02-15 | 2023-05-03 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-02-15 | 2023-05-03 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2023-02-15 | 2023-05-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-06 | 2023-05-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-01-06 | 2023-05-03 | 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 | 2023-01-06 | 2023-05-03 | 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 | 2023-01-06 | 2023-05-03 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-06 | 2023-05-03 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-01-09 | 2023-04-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-09 | 2023-04-07 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-06 | 2023-03-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-06 | 2023-03-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-06 | 2023-03-21 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-01-06 | 2023-03-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-06 | 2023-03-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-06 | 2023-03-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-06 | 2023-03-21 | 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 | 2023-01-06 | 2023-03-21 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-06 | 2023-03-21 | 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 | 2023-01-06 | 2023-03-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-06 | 2023-03-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-06 | 2023-03-21 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-06 | 2023-03-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-06 | 2023-03-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-06 | 2023-03-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-06 | 2023-03-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-06 | 2023-03-21 | Y |
| Meet other general requirements. | Fire Safety | 2023-01-09 | 2023-02-24 | N |
| Use approved construction type or materials. | Fire Safety | 2023-01-09 | 2023-02-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-09 | 2023-02-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-09 | 2023-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-09 | 2023-02-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-09 | 2023-02-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-09 | 2023-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-09 | 2023-02-24 | N |
| 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 | 2022-04-26 | 2022-05-19 | 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 | 2022-04-26 | 2022-05-19 | 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 | 2022-01-19 | 2022-05-19 | 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 | 2022-03-17 | 2022-05-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-05 | 2022-04-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-05 | 2022-04-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-19 | 2022-04-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-19 | 2022-04-26 | 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 | 2022-01-19 | 2022-04-26 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-19 | 2022-04-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-19 | 2022-04-26 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-01-19 | 2022-04-26 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-17 | 2022-04-26 | 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 | 2022-03-17 | 2022-04-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-17 | 2022-04-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-17 | 2022-04-26 | 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 | 2022-03-17 | 2022-04-26 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-17 | 2022-04-26 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-17 | 2022-04-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-17 | 2022-04-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-17 | 2022-04-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-17 | 2022-04-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-17 | 2022-04-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-17 | 2022-04-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-17 | 2022-04-26 | Y |
| 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 | 2022-03-17 | 2022-04-26 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-03-29 | 2022-04-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-29 | 2022-04-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-29 | 2022-04-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-29 | 2022-04-22 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-19 | 2022-03-01 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-19 | 2022-03-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-19 | 2022-03-01 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-19 | 2022-03-01 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-12-08 | 2022-03-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-08 | 2022-01-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-12-08 | 2022-01-19 | 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 | 2021-08-25 | 2021-10-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-15 | 2021-08-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-15 | 2021-08-25 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-06-15 | 2021-08-25 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-06-15 | 2021-07-22 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-06-15 | 2021-07-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-15 | 2021-07-22 | 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 | 2021-06-15 | 2021-07-22 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-06-15 | 2021-07-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-15 | 2021-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-15 | 2021-07-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-15 | 2021-07-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-22 | 2021-07-22 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-07-06 | Not Fixed | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-06 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-06 | Not Fixed | 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 | 2023-07-06 | Not Fixed | Y |
