A list of the most recent deficiencies for Lakeport Post Acute. 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 and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-02-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-27 | 2024-01-23 | N |
| Keep all essential equipment working safely. | Health | 2023-12-18 | 2024-01-19 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-12-18 | 2024-01-18 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-12-18 | 2024-01-18 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-12-18 | 2024-01-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-18 | 2024-01-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-18 | 2024-01-18 | 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 | 2023-12-18 | 2024-01-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-18 | 2024-01-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-12-18 | 2024-01-18 | 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 | 2023-12-18 | 2024-01-18 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-12-18 | 2024-01-18 | N |
| 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 | 2023-12-18 | 2024-01-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-18 | 2024-01-18 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-18 | 2024-01-18 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-12-18 | 2024-01-18 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-18 | 2024-01-18 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-12-18 | 2024-01-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-06 | 2023-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-10-25 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-05-25 | 2023-06-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-03 | 2022-12-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-29 | 2022-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-29 | 2022-09-20 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-07 | 2022-07-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-07 | 2022-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-07 | 2022-07-28 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-06-28 | 2022-07-27 | N |
| 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 | 2022-06-28 | 2022-07-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-28 | 2022-07-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-28 | 2022-07-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-28 | 2022-07-27 | 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 | 2022-06-28 | 2022-07-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-28 | 2022-07-27 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-28 | 2022-07-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-28 | 2022-07-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-28 | 2022-07-27 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-06-28 | 2022-07-27 | 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 | 2022-06-28 | 2022-07-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-28 | 2022-07-27 | 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 | 2022-06-28 | 2022-07-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-28 | 2022-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-28 | 2022-07-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-28 | 2022-07-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-28 | 2022-07-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-29 | 2019-07-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-29 | 2019-07-15 | 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 | 2019-03-29 | 2019-06-17 | 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 | 2019-03-29 | 2019-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-29 | 2019-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-29 | 2019-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-29 | 2019-06-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-29 | 2019-06-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-29 | 2019-06-17 | 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 | 2019-03-29 | 2019-06-17 | 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 | 2019-03-29 | 2019-06-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-29 | 2019-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-29 | 2019-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-29 | 2019-06-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-05-20 | 2019-06-17 | N |
