A list of the most recent deficiencies for The Villa at Great Lakes Crossing. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-14 | 2024-01-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-14 | 2024-01-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-15 | 2023-07-12 | 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 | 2023-06-15 | 2023-07-12 | N |
| 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. | Health | 2023-06-15 | 2023-07-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-06-15 | 2023-07-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-15 | 2023-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-15 | 2023-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-11 | 2022-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-04-01 | N |
| 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. | Health | 2022-03-11 | 2022-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-04-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-07 | 2019-12-06 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-11-07 | 2019-12-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-11-07 | 2019-12-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-07 | 2019-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-07 | 2019-12-06 | 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 | 2019-11-07 | 2019-12-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-07 | 2019-12-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-07 | 2019-12-06 | N |
| Ensure the physician properly assigns and delegates tasks to a physician assistant, nurse practitioner or clinical nurse specialist. | Health | 2019-11-07 | 2019-12-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-11-07 | 2019-12-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-07 | 2019-12-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-11-07 | 2019-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-07 | 2019-12-06 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-11-07 | 2019-12-06 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
