A list of the most recent deficiencies for Lakeridge Villa Health Care Center. 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-06-15 | 2023-06-30 | Y |
| 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 | 2022-03-18 | 2022-06-07 | N |
| Develop a communication plan. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-08 | 2022-06-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-08 | 2022-06-06 | 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 | 2022-03-08 | 2022-06-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-08 | 2022-06-06 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-03-08 | 2022-06-06 | 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 | 2022-03-18 | 2022-06-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-18 | 2022-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-18 | 2022-06-02 | 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 | 2022-03-18 | 2022-06-02 | 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 | 2022-03-18 | 2022-06-02 | N |
| Provide or obtain dental services for each resident. | Health | 2022-03-18 | 2022-06-02 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-03-18 | 2022-06-02 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-03-18 | 2022-06-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-18 | 2022-06-02 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-18 | 2022-06-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-18 | 2022-06-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-18 | 2022-06-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-18 | 2022-06-02 | 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 | 2022-03-18 | 2022-06-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-18 | 2022-06-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-18 | 2022-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-18 | 2022-06-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-18 | 2022-06-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-18 | 2022-06-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-18 | 2022-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-18 | 2022-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-06-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-02-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-27 | 2022-02-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-27 | 2022-02-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-21 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-11-24 | 2021-12-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-24 | 2021-12-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-24 | 2021-12-03 | Y |
| 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 | 2021-11-24 | 2021-12-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-24 | 2021-12-03 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-24 | 2021-12-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-17 | 2021-12-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-26 | 2021-12-03 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-10-15 | 2021-12-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-15 | 2021-12-03 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-09-20 | 2021-12-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-02 | 2021-12-03 | Y |
| Have policies on smoking. | Health | 2021-08-02 | 2021-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-08 | 2021-06-14 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-08 | 2021-06-14 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-06-08 | 2021-06-14 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-06-08 | 2021-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-28 | 2021-06-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-06-14 | Y |
| 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 | 2021-04-06 | 2021-06-14 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-03-03 | 2021-06-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-03 | 2021-06-14 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-03-03 | 2021-06-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-03 | 2021-06-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-03 | 2021-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-03 | 2021-06-14 | Y |
| Post nurse staffing information every day. | Health | 2021-03-03 | 2021-06-14 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-03-03 | 2021-06-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-03 | 2021-06-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-25 | 2019-05-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-25 | 2019-05-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-04-25 | 2019-05-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-25 | 2019-05-31 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-04-25 | 2019-05-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-26 | 2019-05-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-26 | 2019-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-26 | 2019-05-31 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-03-15 | 2018-04-27 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-03-15 | 2018-04-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-15 | 2018-04-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-03-15 | 2018-04-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-15 | 2018-04-27 | N |
| Respond appropriately to all alleged violations. | Health | 2018-03-15 | 2018-04-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-03-15 | 2018-04-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-15 | 2018-04-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-15 | 2018-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-15 | 2018-04-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-15 | 2018-04-27 | 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 | 2018-03-15 | 2018-04-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-15 | 2018-04-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-03-15 | 2018-04-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-03-15 | 2018-04-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-03-15 | 2018-04-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-03-15 | 2018-04-27 | N |
