A list of the most recent deficiencies for Heritage 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-13 | 2024-02-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-13 | 2024-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-13 | 2024-02-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-13 | 2024-02-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-13 | 2024-02-06 | 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 | 2023-12-13 | 2024-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2024-02-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-12 | 2024-01-08 | 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 | 2023-12-12 | 2024-01-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-11-01 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-13 | 2023-09-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-16 | 2023-08-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-16 | 2023-08-17 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-08-16 | 2023-08-17 | 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 | 2023-03-02 | 2023-03-23 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-02 | 2023-03-23 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-03-02 | 2023-03-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-02 | 2023-03-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-02 | 2023-03-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-02 | 2023-03-23 | 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 | 2023-03-02 | 2023-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-03-23 | 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 | 2023-03-02 | 2023-03-23 | 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 | 2023-03-02 | 2023-03-23 | Y |
| Post nurse staffing information every day. | Health | 2023-03-02 | 2023-03-23 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-02 | 2023-03-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-02 | 2023-03-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-02 | 2023-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-02 | 2023-03-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-02 | 2023-03-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-18 | 2023-02-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-18 | 2023-02-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-04 | 2023-02-04 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-26 | 2022-12-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-26 | 2022-12-06 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-10-26 | 2022-12-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-26 | 2022-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-26 | 2022-12-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-12-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-26 | 2022-12-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-26 | 2022-12-06 | 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 | 2022-10-26 | 2022-12-06 | 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 | 2022-10-26 | 2022-12-06 | 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 | 2022-10-26 | 2022-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-26 | 2022-12-06 | N |
| Dispose of garbage and refuse properly. | Health | 2022-10-26 | 2022-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-26 | 2022-12-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-26 | 2022-12-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-26 | 2022-12-06 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-10-26 | 2022-12-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-26 | 2022-12-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-26 | 2022-12-06 | 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 | 2022-10-26 | 2022-12-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-25 | 2022-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-25 | 2022-11-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-25 | 2022-11-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-10-25 | 2022-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-25 | 2022-11-28 | 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 | 2022-09-13 | 2022-09-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-01 | 2022-09-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-01 | 2022-09-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-01 | 2022-09-30 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-01 | 2022-09-30 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-09-01 | 2022-09-30 | 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 necessary and PRN use is limited. | Health | 2022-09-01 | 2022-09-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-01 | 2022-09-30 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-09-01 | 2022-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-25 | 2022-06-16 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-02-16 | 2022-03-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-16 | 2022-03-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-16 | 2022-03-24 | 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 | 2022-02-16 | 2022-03-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-01 | 2021-09-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-01 | 2021-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-01 | 2021-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-01 | 2021-09-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-02 | 2021-09-23 | 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 | 2021-09-02 | 2021-09-23 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-09-02 | 2021-09-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-02 | 2021-09-23 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-09-02 | 2021-09-23 | 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 | 2021-09-02 | 2021-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-02 | 2021-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-02 | 2021-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-02 | 2021-09-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-09-02 | 2021-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-27 | 2021-08-24 | Y |
