Deficiency Records for Edenbrook Lakeside

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Updated as of March 01, 2024

A list of the most recent deficiencies for Edenbrook Lakeside. 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 appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-01-10 2024-02-09 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-12-06 2024-01-02 Y
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 2023-12-06 2024-01-02 Y
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-09-18 2023-12-28 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-09-18 2023-12-28 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 2023-09-18 2023-10-31 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-09-19 2023-10-17 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 2023-09-19 2023-10-17 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 2023-09-19 2023-10-17 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-09-19 2023-10-17 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-09-19 2023-10-17 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-09-19 2023-10-17 Y
Have an enclosure around a vertical opening shaft. Fire Safety 2023-09-18 2023-10-13 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 2023-09-18 2023-10-13 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-09-18 2023-10-13 N
Meet requirements for the use of electrical equipment. Fire Safety 2023-09-18 2023-10-13 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-09-18 2023-10-13 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-05-25 2022-06-24 Y
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 2022-05-25 2022-06-24 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-05-25 2022-06-24 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-05-25 2022-06-24 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-05-25 2022-06-24 Y
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2022-05-25 2022-06-24 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-05-25 2022-06-24 Y
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-05-25 2022-06-24 Y
Post nurse staffing information every day. Health 2022-05-25 2022-06-24 Y
Ensure that residents are free from significant medication errors. Health 2022-05-25 2022-06-24 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-05-25 2022-06-24 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 2022-05-23 2022-06-24 N
Install resident room doors of proper design and width. Fire Safety 2022-05-23 2022-06-24 N
Have an enclosure around a vertical opening shaft. Fire Safety 2022-05-23 2022-06-24 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 2022-05-23 2022-06-24 N
Provide properly protected cooking facilities. Fire Safety 2022-05-23 2022-06-24 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-05-23 2022-06-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-05-23 2022-06-24 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-05-23 2022-06-24 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-05-23 2022-06-24 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2022-05-23 2022-06-24 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-05-23 2022-06-24 N
Meet requirements for the use of electrical equipment. Fire Safety 2022-05-23 2022-06-24 N
Ensure staff are vaccinated for COVID-19 Health 2022-03-01 2022-03-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-01-28 2022-02-16 Y
Provide and implement an infection prevention and control program. Health 2022-01-28 2022-02-16 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-10-27 2021-11-25 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-10-27 2021-11-25 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-07-19 2021-08-09 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-07-19 2021-08-09 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-07-19 2021-08-09 Y
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 2021-05-19 2021-06-15 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-05-19 2021-06-15 Y
Give residents a notice of rights, rules, services and charges. Health 2021-02-11 2021-03-11 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 2021-02-11 2021-03-11 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-02-11 2021-03-11 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-02-11 2021-03-11 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-02-11 2021-03-11 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-02-11 2021-03-11 N
Provide enough food/fluids to maintain a resident's health. Health 2021-02-11 2021-03-11 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2021-02-11 2021-03-11 N
Ensure that residents are free from significant medication errors. Health 2021-02-11 2021-03-11 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-02-11 2021-03-11 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2021-02-10 2021-03-11 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-02-10 2021-03-11 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-02-10 2021-03-11 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-01-24 Not Fixed Y
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2024-01-24 Not Fixed Y