Deficiency Records for Lomond Peak Nursing and Rehabilitation, LLC
Updated as of March 01, 2020
This is not the most recent data for Lomond Peak Nursing and Rehabilitation, LLC. For the most recent information, click here.
A list of the most recent deficiencies for Lomond Peak Nursing and Rehabilitation, LLC. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-10 | 2019-11-04 | 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 | 2019-07-23 | 2019-09-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-23 | 2019-09-20 | Y |
| Implement a program that monitors antibiotic use. | Health | 2019-07-23 | 2019-09-20 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-10 | 2019-09-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-10 | 2019-09-13 | 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 | 2019-09-10 | 2019-09-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-20 | 2019-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-20 | 2019-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-20 | 2019-05-01 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-03-20 | 2019-05-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-20 | 2019-05-01 | 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 | 2019-03-20 | 2019-05-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-20 | 2019-05-01 | 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 | 2019-03-20 | 2019-05-01 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2019-03-20 | 2019-05-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-20 | 2019-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-20 | 2019-05-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-20 | 2019-05-01 | N |
| Ensure that paid feeding assistants have the training they need. | Health | 2019-03-20 | 2019-05-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-03-21 | 2019-04-03 | 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 | 2019-03-21 | 2019-04-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-21 | 2019-04-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-15 | 2019-01-04 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-11-15 | 2019-01-04 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2018-11-15 | 2019-01-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-15 | 2019-01-04 | 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 | 2018-11-15 | 2019-01-04 | Y |
| 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 | 2018-11-15 | 2019-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-15 | 2019-01-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-15 | 2019-01-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-11-15 | 2019-01-04 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-15 | 2019-01-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-15 | 2019-01-04 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-11-15 | 2019-01-04 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-11-15 | 2019-01-04 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-11-15 | 2019-01-04 | Y |
| Provide activities to meet all resident's needs. | Health | 2018-11-15 | 2019-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-15 | 2019-01-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-15 | 2019-01-04 | 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 | 2018-11-15 | 2019-01-04 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-11-15 | 2019-01-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-15 | 2019-01-04 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-11-15 | 2019-01-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-15 | 2019-01-04 | 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 ne | Health | 2018-11-15 | 2019-01-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-11-15 | 2019-01-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-15 | 2019-01-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-11-15 | 2019-01-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-15 | 2019-01-04 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-11-15 | 2019-01-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-11-15 | 2019-01-04 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-06 | 2018-11-30 | 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 | 2018-11-06 | 2018-11-30 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-11 | 2018-08-22 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-09-12 | 2017-10-20 | Y |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-09-12 | 2017-10-20 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-12 | 2017-10-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-04-27 | 2017-06-07 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-27 | 2017-06-07 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-04-27 | 2017-06-07 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-27 | 2017-06-07 | Y |
