A list of the most recent deficiencies for Lake Mills Health Services. 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 receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-10-10 | 2023-11-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-10 | 2023-11-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-10 | 2023-11-09 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-17 | 2022-11-16 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-10-17 | 2022-11-15 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-10-17 | 2022-11-11 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-17 | 2022-11-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-17 | 2022-11-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-17 | 2022-11-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-17 | 2022-11-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-17 | 2022-11-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-17 | 2022-11-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-17 | 2022-11-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-17 | 2022-11-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-10-17 | 2022-11-11 | 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 | 2022-10-17 | 2022-11-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-10-17 | 2022-10-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-22 | 2022-04-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-22 | 2022-04-15 | 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 | 2022-03-22 | 2022-04-15 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-03-22 | 2022-04-15 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-22 | 2022-04-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-31 | 2021-09-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-31 | 2021-09-27 | Y |
| 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 | 2021-07-01 | 2021-08-10 | 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 | 2021-07-01 | 2021-08-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-01 | 2021-08-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-01 | 2021-08-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-01 | 2021-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-01 | 2021-08-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-01 | 2021-08-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-01 | 2021-08-10 | Y |
| 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 | 2021-07-01 | 2021-08-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-01 | 2021-08-10 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-07-01 | 2021-08-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-01 | 2021-08-10 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-07-01 | 2021-08-10 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-01 | 2021-08-10 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-07-01 | 2021-08-10 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-28 | 2021-08-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-28 | 2021-07-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-28 | 2021-07-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-06-28 | 2021-07-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-28 | 2021-07-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-28 | 2021-07-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-28 | 2021-07-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-08 | 2019-05-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-08 | 2019-05-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-08 | 2019-05-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-08 | 2019-05-03 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-08 | 2019-05-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-08 | 2019-05-03 | 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 | 2019-04-08 | 2019-05-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-08 | 2019-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-08 | 2019-05-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-08 | 2019-05-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-08 | 2019-05-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-04-08 | 2019-05-03 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-04-08 | 2019-05-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-08 | 2019-05-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-08 | 2019-05-03 | 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 | 2019-04-08 | 2019-05-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-08 | 2019-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-08 | 2019-05-03 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-04-08 | 2019-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-09 | 2019-05-03 | N |
