A list of the most recent deficiencies for Pleasant Lake Villa. 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? |
|---|---|---|---|---|
| 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 | 2023-11-08 | 2023-11-17 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-08 | 2023-11-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-08 | 2023-11-17 | 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 | 2023-04-27 | 2023-05-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-27 | 2023-05-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-27 | 2023-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-10 | 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 | 2023-04-27 | 2023-05-10 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-04-27 | 2023-05-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-25 | 2023-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-25 | 2023-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-12 | 2022-09-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-12 | 2022-09-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-03 | 2022-06-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-28 | 2022-06-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-28 | 2022-06-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-24 | 2022-03-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-11 | 2021-05-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-11 | 2021-05-20 | Y |
| 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 | 2021-05-11 | 2021-05-20 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-21 | 2019-12-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-21 | 2019-12-11 | 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 | 2019-11-21 | 2019-12-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-21 | 2019-12-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-11-21 | 2019-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-21 | 2019-12-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-11-21 | 2019-12-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-21 | 2019-12-11 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-09-18 | 2018-12-21 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2018-09-20 | 2018-11-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-20 | 2018-11-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-20 | 2018-11-09 | 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 | 2018-09-20 | 2018-11-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-09-20 | 2018-11-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-09-18 | 2018-11-09 | 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 | 2018-09-18 | 2018-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-18 | 2018-11-09 | N |
