Deficiency Records for The Villages of Lapeer Nursing and Rehabilitation
Updated as of April 01, 2019
This is not the most recent data for The Villages of Lapeer Nursing and Rehabilitation. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-11 | 2018-10-08 | Y |
| 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 | 2018-04-05 | 2018-04-24 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2018-04-04 | 2018-04-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-08 | 2018-04-09 | Y |
| 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 ne | Health | 2018-02-12 | 2018-03-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-12 | 2018-03-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-02-12 | 2018-03-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-12 | 2018-03-16 | 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 | 2018-02-12 | 2018-03-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-12 | 2018-03-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-12 | 2018-03-16 | 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 | 2018-02-12 | 2018-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-12 | 2018-03-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-02-12 | 2018-03-16 | 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 | 2018-02-12 | 2018-03-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-02-12 | 2018-03-16 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-02-12 | 2018-03-16 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-02-12 | 2018-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-12 | 2018-03-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Meet other general requirements. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-02-06 | 2018-03-12 | 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 | 2018-02-06 | 2018-03-12 | 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 | 2018-02-06 | 2018-03-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-02-06 | 2018-03-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-12 | 2018-03-12 | N |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-10-31 | 2017-11-22 | Y |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-10-31 | 2017-11-22 | Y |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2017-10-31 | 2017-11-22 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2017-10-31 | 2017-11-22 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-31 | 2017-11-22 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2017-10-31 | 2017-11-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-31 | 2017-11-22 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-10-31 | 2017-11-22 | Y |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-10-31 | 2017-11-22 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-05-24 | 2017-07-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-05-24 | 2017-07-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-24 | 2017-07-02 | 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 | 2017-02-28 | 2017-04-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-02-28 | 2017-04-10 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-03-01 | 2017-04-10 | N |
| Send unopened mail from residents and promptly deliver unopened mail to residents. | Health | 2017-03-01 | 2017-04-10 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-03-01 | 2017-04-10 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-01 | 2017-04-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-01 | 2017-04-10 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-03-01 | 2017-04-10 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-01 | 2017-04-10 | N |
| Provide or obtain dental services for each resident. | Health | 2017-03-01 | 2017-04-10 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-01 | 2017-04-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-01 | 2017-04-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-03-01 | 2017-04-10 | N |
| Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. | Health | 2017-03-01 | 2017-04-10 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-03-01 | 2017-04-10 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-03-01 | 2017-04-10 | Y |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-04-21 | 2016-06-17 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-04-21 | 2016-06-17 | N |
| Properly maintained smoke detectors. | Fire Safety | 2016-04-21 | 2016-06-17 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-04-21 | 2016-06-17 | N |
| No-smoking signs where oxygen is used. | Fire Safety | 2016-04-21 | 2016-06-17 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-04-21 | 2016-05-31 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2016-04-21 | 2016-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-04-21 | 2016-05-31 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-04-21 | 2016-05-31 | N |
