Deficiency Records for The Villa at Traverse Point
Updated as of May 01, 2024
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Deficiency Records for The Villa at Traverse Point
A list of the most recent deficiencies for The Villa at Traverse Point. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Villa at Traverse Point. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-05 | 2023-12-22 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-24 | 2023-09-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-24 | 2023-09-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-24 | 2023-09-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-24 | 2023-09-22 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-24 | 2023-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-24 | 2023-09-22 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-08-24 | 2023-09-22 | N |
| 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. | Health | 2023-08-24 | 2023-09-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-24 | 2023-09-22 | Y |
| 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 | 2023-08-24 | 2023-09-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-24 | 2023-09-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-24 | 2023-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-23 | 2023-07-07 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-11 | 2022-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-11 | 2022-08-11 | 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 | 2022-07-11 | 2022-08-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-11 | 2022-08-11 | N |
| 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. | Health | 2022-07-11 | 2022-08-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-07-11 | 2022-08-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-11 | 2022-08-11 | 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 | 2022-07-11 | 2022-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-11 | 2022-08-11 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-07-11 | 2022-08-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-11 | 2022-08-11 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-11 | 2022-08-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-11 | 2022-08-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-11 | 2022-08-11 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-11 | 2022-08-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-11 | 2022-08-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-11 | 2022-08-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-11 | 2022-08-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-11 | 2022-08-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-11 | 2022-08-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-11 | 2022-08-11 | Y |
| 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 | 2022-07-11 | 2022-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-11 | 2022-08-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-07-11 | 2022-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-11 | 2022-08-11 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-29 | 2022-08-11 | 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 | 2022-06-29 | 2022-08-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-29 | 2022-08-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-29 | 2022-08-11 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-11-09 | 2021-12-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-09 | 2021-12-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-09 | 2021-12-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-09 | 2021-12-09 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-11-09 | 2021-12-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-08-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-23 | 2021-04-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-23 | 2021-04-19 | 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 | 2021-03-23 | 2021-04-19 | N |
| 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. | Health | 2021-03-23 | 2021-04-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-23 | 2021-04-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-23 | 2021-04-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-23 | 2021-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-23 | 2021-04-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-23 | 2021-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-23 | 2021-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-23 | 2021-04-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-23 | 2021-04-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-23 | 2021-04-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-23 | 2021-04-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-23 | 2021-04-19 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-03-23 | 2021-04-19 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-03-23 | 2021-04-19 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-03-23 | 2021-04-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-03-23 | 2021-04-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-23 | 2021-04-19 | 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 | 2021-03-23 | 2021-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-23 | 2021-04-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-23 | 2021-04-19 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-03-23 | 2021-04-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-17 | 2021-04-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-03-17 | 2021-04-19 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-03-17 | 2021-04-19 | 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 | 2021-03-17 | 2021-04-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-17 | 2021-04-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-17 | 2021-04-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-17 | 2021-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-17 | 2021-04-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-17 | 2021-04-19 | N |
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