Deficiency Records for The Waters of Lagrange Skilled Nursing Facility
Updated as of April 01, 2024
A list of the most recent deficiencies for The Waters of Lagrange Skilled Nursing Facility. 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? |
|---|---|---|---|---|
| Establish staff and initial training requirements. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-12-27 | 2024-01-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-01 | 2024-01-08 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-01 | 2024-01-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-12-01 | 2024-01-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-01 | 2024-01-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2024-01-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-12-01 | 2024-01-08 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-12-01 | 2024-01-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-01 | 2024-01-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-16 | 2023-09-01 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-12 | 2023-01-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-01-12 | 2023-01-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-12 | 2023-01-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-12 | 2023-01-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-12-19 | 2023-01-09 | N |
| Dispose of garbage and refuse properly. | Health | 2022-12-19 | 2023-01-09 | N |
| 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. | Health | 2021-11-23 | 2022-01-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-09 | 2021-12-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-09 | 2021-12-21 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-12-09 | 2021-12-21 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-11-23 | 2021-12-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-23 | 2021-12-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-23 | 2021-12-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-23 | 2021-12-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-23 | 2021-12-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-23 | 2021-12-14 | N |
| 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. | Health | 2021-11-23 | 2021-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-23 | 2021-12-14 | N |
| 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 | 2021-11-23 | 2021-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-23 | 2021-12-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-23 | 2021-12-14 | N |
