Deficiency Records for Trail Lake Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Trail Lake 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-29 | 2023-12-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-29 | 2023-12-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-29 | 2023-12-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-29 | 2023-12-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-29 | 2023-12-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-29 | 2023-12-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-15 | 2023-12-18 | 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 | 2023-11-30 | 2023-12-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-30 | 2023-12-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-30 | 2023-12-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-11-30 | 2023-12-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-30 | 2023-12-18 | N |
| Provide appropriate foot care. | Health | 2023-11-30 | 2023-12-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-30 | 2023-12-18 | 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 | 2023-11-30 | 2023-12-18 | 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 | 2023-11-30 | 2023-12-18 | 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 | 2023-11-30 | 2023-12-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2023-12-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-30 | 2023-12-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-30 | 2023-12-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-30 | 2023-12-18 | 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 | 2023-11-30 | 2023-12-18 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-11-30 | 2023-12-18 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2023-11-30 | 2023-12-18 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-30 | 2023-12-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-21 | 2023-10-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-24 | 2023-08-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-24 | 2023-08-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-02 | 2023-08-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-02 | 2023-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-02 | 2023-08-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-02 | 2023-08-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-02 | 2023-08-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-08-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-31 | 2023-08-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-08 | 2023-06-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-08 | 2023-06-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-08 | 2023-06-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-08 | 2023-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-06-09 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-11 | 2023-05-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-22 | 2023-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-22 | 2023-02-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-18 | 2023-01-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-18 | 2023-01-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-27 | 2023-01-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-27 | 2023-01-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-26 | 2022-11-04 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-15 | 2022-10-07 | 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 | 2022-09-15 | 2022-10-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-15 | 2022-10-07 | 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 | 2022-09-15 | 2022-10-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-15 | 2022-10-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-15 | 2022-10-07 | 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 | 2022-06-16 | 2022-07-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-16 | 2022-07-07 | 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 | 2022-06-16 | 2022-07-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-16 | 2022-07-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-16 | 2022-07-07 | 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 | 2022-04-20 | 2022-04-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-20 | 2022-04-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-29 | 2022-04-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-29 | 2022-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-21 | 2021-12-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-27 | 2021-11-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-27 | 2021-11-22 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-27 | 2021-11-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-27 | 2021-10-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-31 | 2021-09-20 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-13 | 2021-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-13 | 2021-08-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-13 | 2021-08-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-13 | 2021-08-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-13 | 2021-08-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-13 | 2021-08-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-13 | 2021-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-19 | 2021-07-25 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-19 | 2021-07-25 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-07-15 | 2021-07-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-07-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-07-20 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-07-13 | 2021-07-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-07-13 | 2021-07-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-07-13 | 2021-07-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-07-13 | 2021-07-20 | N |
| Develop a communication plan. | Fire Safety | 2021-07-13 | 2021-07-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-07-13 | 2021-07-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-13 | 2021-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-22 | 2021-05-01 | Y |
