Deficiency Records for Lakeshore Village Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Lakeshore Village Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-16 | 2024-01-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-16 | 2024-01-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-16 | 2024-01-12 | 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 | 2023-12-16 | 2024-01-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-16 | 2024-01-12 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-12-16 | 2024-01-12 | N |
| Provide or obtain dental services for each resident. | Health | 2023-12-16 | 2024-01-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-16 | 2024-01-12 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-12-16 | 2024-01-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-16 | 2024-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-16 | 2024-01-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-16 | 2024-01-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-16 | 2024-01-12 | 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 | 2023-12-16 | 2024-01-12 | Y |
| 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 | 2023-12-16 | 2024-01-12 | 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 | 2023-12-16 | 2024-01-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-16 | 2024-01-12 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-12-16 | 2024-01-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-16 | 2024-01-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-16 | 2024-01-12 | 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 | 2023-12-16 | 2024-01-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-16 | 2024-01-12 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-12-16 | 2024-01-12 | Y |
| 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 | 2023-12-16 | 2024-01-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-16 | 2024-01-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-16 | 2024-01-12 | Y |
| 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 | 2023-12-16 | 2024-01-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-16 | 2024-01-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-16 | 2024-01-12 | 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 | 2023-12-16 | 2024-01-12 | 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 | 2023-12-16 | 2024-01-12 | Y |
| Have policies on smoking. | Health | 2023-12-16 | 2024-01-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-17 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-26 | 2023-06-27 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-02 | 2023-02-09 | Y |
| 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 | 2023-01-10 | 2023-01-17 | Y |
| 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 | 2022-10-24 | 2022-10-25 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-22 | 2021-10-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-20 | 2021-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-20 | 2021-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-20 | 2021-09-20 | N |
| Keep all essential equipment working safely. | Health | 2021-08-20 | 2021-09-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-20 | 2021-09-20 | N |
