A list of the most recent deficiencies for Lake Country 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-09 | 2023-11-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-09 | 2023-11-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-09 | 2023-11-08 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-04-12 | 2023-05-10 | 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 | 2023-04-12 | 2023-05-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-12 | 2023-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-12 | 2023-05-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-12 | 2023-05-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-12 | 2023-05-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-12 | 2023-05-10 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-11 | 2023-05-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-11 | 2023-05-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-11 | 2023-05-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-11 | 2023-05-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-11 | 2023-05-10 | 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 | 2022-02-03 | 2022-03-01 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-03 | 2022-03-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-03 | 2022-03-01 | 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 | 2022-02-03 | 2022-03-01 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-02-03 | 2022-03-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-03 | 2022-03-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-01 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-02 | 2022-03-01 | 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 | 2022-02-02 | 2022-03-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-02 | 2022-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-02 | 2022-03-01 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-02-02 | 2022-03-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-02 | 2022-03-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-03 | 2021-11-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-11-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-03 | 2021-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-14 | 2021-08-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-14 | 2021-08-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-08-02 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-09-25 | 2019-10-25 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-09-25 | 2019-10-25 | N |
| 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 | 2019-09-25 | 2019-10-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-25 | 2019-10-25 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-25 | 2019-10-25 | 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 | 2019-09-25 | 2019-10-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-25 | 2019-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-25 | 2019-10-25 | 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 | 2019-09-25 | 2019-10-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-25 | 2019-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-25 | 2019-10-25 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-24 | 2019-10-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-24 | 2019-10-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-24 | 2019-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-24 | 2019-10-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-24 | 2019-10-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-09-24 | 2019-10-25 | N |
