Deficiency Records for The Villages of Lapeer Nursing and Rehabilitation
Updated as of February 01, 2023
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| 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 |
