Inspection visit
Inspection
Citations
50 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0001GeneralS&S Dpotential for harm
Establish an Emergency Preparedness Program (EP).
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0291GeneralS&S Dpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F693 - Assisted nutrition and hydration
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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F849 - Hospice services
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.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F559 - The right to share a room with his or her spouse when married residents live
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F687 - Foot care
Provide appropriate foot care.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
F584 - Safe Environment
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.
F920 - Dining and Resident Activities
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
F924 - Equip corridors with firmly secured handrails on each side
Put firmly secured handrails on each side of hallways.
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.
F807 - Food and drink
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
F837 - Governing body
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.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
FAQ · About this visit
Common questions about this visit
What happened during the January 25, 2024 survey of LAKE MARIAM HEALTH AND REHABILITATION CENTER?
This was a inspection survey of LAKE MARIAM HEALTH AND REHABILITATION CENTER on January 25, 2024. The surveyor cited 50 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LAKE MARIAM HEALTH AND REHABILITATION CENTER on January 25, 2024?
Yes, 50 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.