Care Citations

Blue Lake Post Acute

991 E NEW YORK AVE, DELAND, FL, 32724 · 3867349083

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
1 / 5
Staffing rating
1 / 5
Certified beds
60
Ownership type
For profit - Corporation
Chain
ELEVATION HEALTHCARE

Inspection findings on record (28)

Quoted exactly as CMS published them. We do not rewrite findings.

— Nursing and Physician Services Deficiencies

Tag 0727 · scope/severity F · potential for more than minimal harm

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.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0732 · scope/severity F · potential for more than minimal harm

Post nurse staffing information every day.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0638 · scope/severity E · potential for more than minimal harm

Assure that each resident’s assessment is updated at least once every 3 months.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity E · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity D · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0554 · scope/severity D · potential for more than minimal harm

Allow residents to self-administer drugs if determined clinically appropriate.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0676 · scope/severity D · potential for more than minimal harm

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0687 · scope/severity E · potential for more than minimal harm

Provide appropriate foot care.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity J · immediate jeopardy

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity J · immediate jeopardy

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity J · immediate jeopardy

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity J · immediate jeopardy

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0624 · scope/severity D · potential for more than minimal harm

Prepare residents for a safe transfer or discharge from the nursing home.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0865 · scope/severity F · potential for more than minimal harm

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

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0636 · scope/severity E · potential for more than minimal harm

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0638 · scope/severity E · potential for more than minimal harm

Assure that each resident’s assessment is updated at least once every 3 months.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity D · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0625 · scope/severity D · potential for more than minimal harm

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0644 · scope/severity D · potential for more than minimal harm

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 105262