LAKESHORE WEDGEWOOD

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Tennessee are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Short-Term Stay Preventive Actions

Short-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 11/24/2009.

Administration

1) Review the Work of Each Nurse Aide Every Year; or 2) Give Regular Training for the Nurse Aides. Inspection Date: 11/24/2009 Correction Date: 12/03/2009
Set Up or Keep a Group of People to Review and Ensure Quality. Inspection Date: 11/24/2009 Correction Date: 12/03/2009

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 06/20/2007 Correction Date: 07/23/2007
Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 09/09/2008 Correction Date: 10/10/2008
Make Sure That the Attending Doctor Orders Special Diets. Inspection Date: 09/09/2008 Correction Date: 10/10/2008
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 09/09/2008 Correction Date: 10/10/2008
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 11/24/2009 Correction Date: 12/03/2009

Pharmacy Service

Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 06/20/2007 Correction Date: 07/23/2007

Quality Care

Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 06/20/2007 Correction Date: 07/23/2007
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 06/20/2007 Correction Date: 07/23/2007
Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 09/09/2008 Correction Date: 10/10/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 11/24/2009 Correction Date: 12/03/2009

Resident Assessment

1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 06/20/2007 Correction Date: 07/23/2007
Do a New Assessment After Any Major Change in a Resident's Physical or Mental Health. Inspection Date: 09/09/2008 Correction Date: 10/24/2008
1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 09/09/2008 Correction Date: 10/24/2008

Resident Rights

Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged. Inspection Date: 06/20/2007 Correction Date: 07/23/2007

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Lakeshore Wedgewood had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 11/23/2009.

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 06/18/2007 Correction Date: 09/06/2007
Back-Up Procedures in Place for a Faulty Automatic Sprinkler System. Inspection Date: 06/18/2007 Correction Date: 09/06/2007
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 09/07/2008 Correction Date: 10/24/2008
Portable Fire Extinguishers. Inspection Date: 09/07/2008 Correction Date: 09/26/2008
Portable Fire Extinguishers. Inspection Date: 11/23/2009 Correction Date: 12/03/2009

Building Construction

A Two-Hour-Resistant Firewall in Common Walls. Inspection Date: 06/18/2007 Correction Date: 09/06/2007

Building Service Equipment

Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions. Inspection Date: 09/07/2008 Correction Date: 09/15/2008
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions. Inspection Date: 11/23/2009 Correction Date: 12/03/2009

Corridor Walls and Doors

Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of Smoke. Inspection Date: 06/18/2007 Correction Date: 09/06/2007
Corridor and Hallway Doors That Block Smoke. Inspection Date: 06/18/2007 Correction Date: 09/06/2007

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 06/18/2007 Correction Date: 09/06/2007
Properly Installed Electrical Wiring and Equipment. Inspection Date: 09/07/2008 Correction Date: 09/26/2008
Properly Installed Electrical Wiring and Equipment. Inspection Date: 11/23/2009 Correction Date: 12/03/2009

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 09/07/2008 Correction Date: 10/24/2008
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 11/23/2009 Correction Date: 12/03/2009

Exits and Egress

Exits That Are Accessible at All Times. Inspection Date: 11/23/2009 Correction Date: 12/03/2009

Fire Alarm Systems

An Approved Back-Up Procedure for a Faulty Fire Alarm System. Inspection Date: 06/18/2007 Correction Date: 09/06/2007
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 09/07/2008 Correction Date: 09/07/2008
Properly Maintained Smoke Detectors. Inspection Date: 09/07/2008 Correction Date: 09/26/2008
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 11/23/2009 Correction Date: 12/03/2009

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 06/18/2007 Correction Date: 09/06/2007
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 09/07/2008 Correction Date: 09/26/2008

Illumination and Emergency Power

Emergency Lighting That Can Last at Least 1 1/2 Hours. Inspection Date: 11/23/2009 Correction Date: 12/03/2009
Properly Located and Lighted "Exit" Signs. Inspection Date: 11/23/2009 Correction Date: 12/03/2009

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas. Inspection Date: 06/18/2007 Correction Date: 09/06/2007

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour. Inspection Date: 06/18/2007 Correction Date: 09/06/2007