Deficiency Records for The Villages of Lapeer Nursing and Rehabilitation
Updated as of June 01, 2022
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? |
---|---|---|---|---|
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 |
Have an externally vented heating system. | Fire Safety | 2021-07-29 | 2021-09-21 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-29 | 2021-09-17 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-08-04 | 2021-09-03 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-04 | 2021-09-03 | N |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-04 | 2021-09-03 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-04 | 2021-09-03 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-04 | 2021-09-03 | N |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-08-04 | 2021-09-03 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-04 | 2021-09-03 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-04 | 2021-09-03 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-04 | 2021-09-03 | N |
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-08-04 | 2021-09-03 | N |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-08-04 | 2021-09-03 | 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 | 2021-08-04 | 2021-09-03 | 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 | 2021-08-04 | 2021-09-03 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-09-03 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-29 | 2021-09-03 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-29 | 2021-09-03 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-07-29 | 2021-09-03 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-29 | 2021-09-03 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-29 | 2021-09-03 | N |
Have restrictions on the use of portable space heaters. | Fire Safety | 2021-07-29 | 2021-09-03 | N |
Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-07-29 | 2021-09-03 | 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 |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-01-14 | 2021-05-28 | N |
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 |
Reasonably accommodate the needs and preferences of each resident. | Health | 2021-01-21 | 2021-02-23 | 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 | 2021-01-21 | 2021-02-23 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-01-21 | 2021-02-23 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-01-21 | 2021-02-23 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-01-21 | 2021-02-23 | 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 | 2021-01-21 | 2021-02-23 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-01-21 | 2021-02-23 | N |
Provide activities to meet all resident's needs. | Health | 2021-01-21 | 2021-02-23 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-01-21 | 2021-02-23 | 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 | 2021-01-21 | 2021-02-23 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-01-21 | 2021-02-23 | 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 | 2021-01-21 | 2021-02-23 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-01-21 | 2021-02-23 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-01-21 | 2021-02-23 | N |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-01-21 | 2021-02-23 | 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 | 2021-01-21 | 2021-02-23 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-01-21 | 2021-02-23 | N |
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 necessary and PRN use is limited. | Health | 2021-01-21 | 2021-02-23 | 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 | 2021-01-21 | 2021-02-23 | N |
Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-01-21 | 2021-02-23 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-01-21 | 2021-02-23 | N |
Provide and implement an infection prevention and control program. | Health | 2021-01-21 | 2021-02-23 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2021-01-14 | 2021-02-23 | N |
Provide properly protected cooking facilities. | Fire Safety | 2021-01-14 | 2021-02-23 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2021-01-14 | 2021-02-23 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-01-14 | 2021-02-23 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-08-19 | 2020-09-28 | Y |
Respond appropriately to all alleged violations. | Health | 2020-08-19 | 2020-09-28 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-08-19 | 2020-09-28 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-08-19 | 2020-09-28 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-08-19 | 2020-09-28 | Y |
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 | 2020-08-19 | 2020-09-28 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-08-19 | 2020-09-28 | Y |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-08-19 | 2020-09-28 | Y |
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2020-08-19 | 2020-09-28 | Y |
Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. | Health | 2020-08-19 | 2020-09-28 | Y |
Assess the resident when there is a significant change in condition | Health | 2020-07-08 | 2020-09-18 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-07-08 | 2020-09-18 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-07-08 | 2020-09-18 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-07-08 | 2020-09-18 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-07-08 | 2020-09-18 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-07-08 | 2020-09-18 | 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 | 2020-07-08 | 2020-09-18 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2020-07-08 | 2020-09-18 | Y |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2020-07-08 | 2020-09-18 | Y |
Ensure that residents are free from significant medication errors. | Health | 2020-07-08 | 2020-09-18 | Y |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-08-06 | 2020-09-18 | Y |
Implement emergency and standby power systems. | Fire Safety | 2020-08-06 | 2020-09-18 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-04-15 | 2020-05-16 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-04-15 | 2020-05-15 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-25 | 2019-10-24 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-05 | 2019-10-15 | Y |
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 | 2019-09-05 | 2019-10-15 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-05 | 2019-10-15 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-05 | 2019-10-15 | Y |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-09-05 | 2019-10-15 | Y |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-05 | 2019-10-15 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-20 | 2019-09-29 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-20 | 2019-09-29 | Y |
Respond appropriately to all alleged violations. | Health | 2019-08-20 | 2019-09-29 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-20 | 2019-09-29 | 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 | 2019-08-20 | 2019-09-29 | Y |
Post nurse staffing information every day. | Health | 2019-08-20 | 2019-09-29 | Y |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-08-20 | 2019-09-29 | Y |