Deficiency Records for The Villages of Lapeer Nursing and Rehabilitation

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Updated as of March 01, 2024

A list of the most recent deficiencies for The Villages of Lapeer Nursing and Rehabilitation. 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?
Meet other general requirements. Fire Safety 2023-06-06 2023-06-24 Y
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2023-06-06 2023-06-24 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-02-07 2023-02-20 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-02-07 2023-02-20 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2023-02-07 2023-02-20 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-02-07 2023-02-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-02-07 2023-02-20 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 2023-02-02 2023-02-20 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 2023-02-02 2023-02-20 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-08-10 2022-11-09 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2022-08-10 2022-08-25 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-08-10 2022-08-25 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-08-03 2022-08-19 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-08-03 2022-08-19 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 2022-08-03 2022-08-19 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2022-03-17 2022-04-01 Y
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2022-02-03 2022-02-23 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-02-03 2022-02-23 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-02-03 2022-02-23 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-02-03 2022-02-23 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 2022-02-03 2022-02-23 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2022-02-03 2022-02-23 N
Provide and implement an infection prevention and control program. Health 2022-02-03 2022-02-23 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2022-02-03 2022-02-23 N
Establish policies and procedures for sheltering. Fire Safety 2022-02-03 2022-02-23 N
Establish roles under a Waiver declared by secretary. Fire Safety 2022-02-03 2022-02-23 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 2022-02-03 2022-02-23 N
Ensure that sources of ignition are removed from patients receiving respiratory therapy. Fire Safety 2022-02-03 2022-02-23 N
Ensure each resident receives an accurate assessment. Health 2021-06-16 2021-07-09 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-06-16 2021-07-09 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-06-16 2021-07-09 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-04-09 2021-05-17 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2021-04-09 2021-05-17 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-04-09 2021-05-17 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2021-04-09 2021-05-17 Y
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Health 2021-04-09 2021-05-17 Y
Provide and implement an infection prevention and control program. Health 2021-04-09 2021-05-17 Y