A list of the most recent deficiencies for Lakeside Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-06-03 | 2023-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-03 | 2023-10-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-03 | 2023-09-05 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-31 | 2023-02-10 | N |
| Meet the legal definition of a skilled nursing facility or nursing facility. | Health | 2022-05-23 | 2022-08-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-23 | 2022-08-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-05-23 | 2022-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-23 | 2022-08-10 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-05-23 | 2022-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-23 | 2022-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-23 | 2022-08-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-23 | 2022-08-10 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-05-23 | 2022-08-10 | 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 | 2022-05-23 | 2022-08-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-23 | 2022-08-10 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-05-23 | 2022-08-10 | Y |
| Meet the legal definition of a skilled nursing facility or nursing facility. | Health | 2022-07-07 | 2022-08-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-07 | 2022-08-10 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-07 | 2022-08-10 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-07 | 2022-08-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-07 | 2022-08-10 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-07-07 | 2022-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-07 | 2022-08-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-07 | 2022-08-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-07 | 2022-08-10 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-07-07 | 2022-08-10 | 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 | 2022-07-07 | 2022-08-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-07 | 2022-08-10 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-07-07 | 2022-08-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-07 | 2022-08-10 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-07-07 | 2022-08-10 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-05-23 | 2022-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-23 | 2022-08-10 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-05-23 | 2022-08-10 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-03 | 2022-07-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-23 | 2022-06-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-23 | 2022-06-30 | 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 | 2022-05-23 | 2022-06-30 | 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 | 2022-05-23 | 2022-06-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-23 | 2022-06-30 | N |
| 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 | 2022-05-23 | 2022-06-30 | 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 | 2022-05-23 | 2022-06-30 | N |
| Provide appropriate foot care. | Health | 2022-05-23 | 2022-06-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-23 | 2022-06-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-05-23 | 2022-06-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-05-23 | 2022-06-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-23 | 2022-06-30 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-23 | 2022-06-30 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-05-23 | 2022-06-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-23 | 2022-06-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-23 | 2022-06-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-23 | 2022-06-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-23 | 2022-06-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-23 | 2022-06-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-23 | 2022-06-30 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2022-05-23 | 2022-06-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-23 | 2022-06-30 | 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 | 2019-05-07 | 2019-07-31 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-05-07 | 2019-07-18 | 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 | 2019-05-07 | 2019-07-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-07 | 2019-07-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-02 | 2019-06-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-02 | 2019-06-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-02 | 2019-06-11 | 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 | 2019-05-02 | 2019-06-11 | 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 | 2019-05-02 | 2019-06-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-02 | 2019-06-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-02 | 2019-06-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-02 | 2019-06-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-06-11 | 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 | 2019-05-02 | 2019-06-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-02 | 2019-06-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-02 | 2019-06-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-02 | 2019-06-11 | 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 | 2019-05-02 | 2019-06-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-02 | 2019-06-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-02 | 2019-06-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-02 | 2019-06-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-02 | 2019-06-11 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2019-05-02 | 2019-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-02 | 2019-06-11 | N |
| Dispose of garbage and refuse properly. | Health | 2019-05-02 | 2019-06-11 | N |
| 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 | 2019-05-02 | 2019-06-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-02 | 2019-06-11 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2019-05-02 | 2019-06-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-13 | 2018-05-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-04-13 | 2018-05-13 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-04-13 | 2018-05-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-13 | 2018-05-13 | 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 | 2018-04-13 | 2018-05-13 | 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 | 2018-04-13 | 2018-05-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-13 | 2018-05-13 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-04-13 | 2018-05-13 | N |
| 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 | 2018-04-13 | 2018-05-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-13 | 2018-05-13 | 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 | 2018-04-13 | 2018-05-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-13 | 2018-05-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-13 | 2018-05-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-13 | 2018-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-13 | 2018-05-13 | 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 | 2018-04-13 | 2018-05-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-04-13 | 2018-05-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-04-13 | 2018-05-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-13 | 2018-05-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-13 | 2018-05-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-04-13 | 2018-05-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-04-13 | 2018-05-13 | 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 | 2018-04-13 | 2018-05-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-13 | 2018-05-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-13 | 2018-05-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-04-13 | 2018-05-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-04-13 | 2018-05-13 | N |
