Deficiency Records for Grand Lake Villa
Updated as of August 01, 2023
This is not the most recent data for Grand Lake Villa. For the most recent information, click here.
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? |
---|---|---|---|---|
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 |
Provide and implement an infection prevention and control program. | Health | 2020-10-22 | 2020-11-13 | Y |
Report COVID19 data to residents and families. | Health | 2020-10-22 | 2020-11-13 | Y |
Perform COVID19 testing on residents and staff. | Health | 2020-10-22 | 2020-11-13 | 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 |
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2016-12-15 | 2017-01-16 | N |
Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2016-12-15 | 2017-01-16 | N |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-12-15 | 2017-01-16 | N |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-15 | 2017-01-16 | N |
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-12-15 | 2017-01-16 | N |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-15 | 2017-01-16 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-15 | 2017-01-16 | N |
Ensure residents maintain acceptable nutritional status. | Health | 2016-12-15 | 2017-01-16 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-12-15 | 2017-01-16 | N |
Ensure laboratory services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or have an agreement to obtain services from an offsite laboratory, that meets the same requirements. | Health | 2016-12-15 | 2017-01-16 | N |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-15 | 2017-01-16 | N |
Have exits that are accessible at all times. | Fire Safety | 2016-12-14 | 2017-01-16 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-12-14 | 2017-01-16 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2016-12-14 | 2017-01-16 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-12-14 | 2017-01-16 | N |