The Lakeland Center

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Administration Deficiencies

Have a Compliance and Ethics Program.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Nursing and Physician Services Deficiencies

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.

Resident Rights Deficiencies

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.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Nursing and Physician Services Deficiencies

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Pharmacy Service Deficiencies

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.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

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.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Nursing and Physician Services Deficiencies

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Pharmacy Service Deficiencies

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.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

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.