Deficiency Records for Lake Emory Post Acute Care
Updated as of November 01, 2023
This is not the most recent data for Lake Emory Post Acute Care. For the most recent information, click here.
A list of the most recent deficiencies for Lake Emory Post Acute Care. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-24 | 2023-10-11 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-20 | 2023-04-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-20 | 2023-04-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-20 | 2023-04-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-03-20 | 2023-04-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-20 | 2023-04-19 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-02-03 | 2023-03-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-03 | 2023-03-14 | 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 | 2023-02-03 | 2023-03-14 | 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 | 2023-02-03 | 2023-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-03 | 2023-03-14 | 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 | 2022-02-23 | 2022-03-09 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-06-24 | 2021-07-23 | N |
| 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 | 2021-06-24 | 2021-07-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-24 | 2021-07-23 | 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 | 2021-06-24 | 2021-07-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-24 | 2021-07-23 | 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 | 2021-06-24 | 2021-07-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-24 | 2021-07-23 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-04-05 | 2021-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-05 | 2021-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-12-17 | 2021-01-08 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-25 | 2019-05-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-25 | 2019-05-24 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-04-25 | 2019-05-24 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-25 | 2019-05-24 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-04-25 | 2019-05-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-25 | 2019-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-25 | 2019-05-24 | 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 | 2019-04-25 | 2019-05-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-25 | 2019-05-24 | 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 | 2019-04-25 | 2019-05-24 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-04-25 | 2019-05-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-25 | 2019-05-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-25 | 2019-05-24 | 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 | 2019-04-25 | 2019-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-25 | 2019-05-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-25 | 2019-05-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-04-25 | 2019-05-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-24 | 2019-05-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-24 | 2019-05-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-24 | 2019-05-24 | N |
