Deficiency Records for Five Points at Lake Highlands Nursing and Rehab
Updated as of September 01, 2020
This is not the most recent data for Five Points at Lake Highlands Nursing and Rehab. For the most recent information, click here.
A list of the most recent deficiencies for Five Points at Lake Highlands Nursing and Rehab. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-02-11 | 2020-02-24 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-25 | 2019-12-01 | 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 | 2019-10-25 | 2019-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-25 | 2019-12-01 | Y |
| 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 | 2019-10-25 | 2019-12-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-25 | 2019-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-10-25 | 2019-12-01 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-25 | 2019-12-01 | Y |
| Have policies on smoking. | Health | 2019-10-25 | 2019-12-01 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-22 | 2019-11-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-22 | 2019-11-07 | 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 | 2019-10-22 | 2019-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-22 | 2019-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-22 | 2019-10-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-14 | 2019-06-28 | 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 | 2018-10-04 | 2018-11-09 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-04 | 2018-11-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-05 | 2018-11-01 | N |
| Respond appropriately to all alleged violations. | Health | 2018-10-05 | 2018-11-01 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2018-10-05 | 2018-11-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-10-05 | 2018-11-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-31 | 2018-08-05 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| 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 | 2017-09-28 | 2017-10-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-09-28 | 2017-10-27 | 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 | 2017-09-28 | 2017-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-09-28 | 2017-10-27 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-29 | 2017-10-27 | N |
| Dispose of garbage and refuse properly. | Health | 2017-09-29 | 2017-10-27 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-09-29 | 2017-10-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-09-29 | 2017-10-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-09-29 | 2017-10-27 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-09-29 | 2017-10-27 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-09-29 | 2017-10-27 | Y |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-09-29 | 2017-10-27 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2017-09-29 | 2017-10-27 | Y |
