A list of the most recent deficiencies for Covenant Village of The Great Lakes. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-26 | 2024-02-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-26 | 2024-02-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-26 | 2024-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-26 | 2024-02-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-26 | 2024-02-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-26 | 2024-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-26 | 2024-02-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-26 | 2024-02-14 | 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 | 2024-01-26 | 2024-02-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-26 | 2024-02-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-11 | 2023-02-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-11 | 2023-02-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-11 | 2023-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-11 | 2023-02-03 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-11 | 2023-02-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-11 | 2023-02-03 | 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 | 2023-01-11 | 2023-02-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-11 | 2023-02-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-11 | 2023-02-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-11 | 2023-02-03 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-11 | 2023-02-03 | Y |
| 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 | 2023-01-11 | 2023-02-03 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-01-11 | 2023-02-03 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-09 | 2023-02-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-09 | 2023-02-03 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-28 | 2022-11-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-10-28 | 2022-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-11-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-30 | 2021-10-22 | N |
| 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. | Health | 2021-09-30 | 2021-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-30 | 2021-10-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-30 | 2021-10-22 | N |
| Post nurse staffing information every day. | Health | 2021-09-30 | 2021-10-22 | 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 | 2021-09-30 | 2021-10-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-10-22 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-09-30 | 2021-10-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-07 | 2021-10-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-07 | 2021-10-22 | N |
