A list of the most recent deficiencies for Grand 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-11 | 2023-09-21 | 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 | 2023-08-11 | 2023-09-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-11 | 2023-09-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-11 | 2023-09-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-11 | 2023-09-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-05 | 2023-07-03 | 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 | 2023-05-05 | 2023-07-03 | 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 | 2023-05-05 | 2023-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-05 | 2023-07-03 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-07-05 | 2022-07-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-05 | 2022-07-15 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-10-20 | 2021-11-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-20 | 2021-11-10 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-30 | 2019-10-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-30 | 2019-09-13 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-05-30 | 2019-06-30 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-05-30 | 2019-06-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-05-30 | 2019-06-30 | 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 | 2019-05-30 | 2019-06-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-30 | 2019-06-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-05-30 | 2019-06-30 | 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 | 2019-05-30 | 2019-06-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-30 | 2019-06-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-22 | 2019-06-30 | 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 | 2019-05-22 | 2019-06-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-05-22 | 2019-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-22 | 2019-06-30 | N |
| Have an externally vented heating system. | Fire Safety | 2019-05-22 | 2019-06-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-22 | 2019-06-30 | 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 | 2018-02-22 | 2018-03-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-22 | 2018-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-02-22 | 2018-03-22 | 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 | 2018-02-22 | 2018-03-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-22 | 2018-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-22 | 2018-03-22 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-02-22 | 2018-03-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-02-22 | 2018-03-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-22 | 2018-03-22 | N |
| Provide activities to meet all resident's needs. | Health | 2018-02-22 | 2018-03-22 | 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 | 2018-02-22 | 2018-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-22 | 2018-03-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-02-22 | 2018-03-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-22 | 2018-03-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-02-22 | 2018-03-22 | 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 | 2018-02-22 | 2018-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-22 | 2018-03-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-02-22 | 2018-03-22 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-14 | 2018-03-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-14 | 2018-03-22 | 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 | 2018-02-14 | 2018-03-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-02-14 | 2018-03-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-14 | 2018-03-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-14 | 2018-03-22 | N |
