A list of the most recent deficiencies for Lecom at Village Square, LLC. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-07 | 2024-02-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-07 | 2024-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-07 | 2024-02-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-07 | 2024-02-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-07 | 2024-02-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Meet other general requirements. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-12-12 | 2024-01-31 | 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 | 2023-12-12 | 2024-01-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-12 | 2024-01-31 | 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 | 2023-12-12 | 2024-01-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-07 | 2023-03-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-02-07 | 2023-03-20 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-02-07 | 2023-03-20 | N |
| Use approved construction type or materials. | Fire Safety | 2023-02-07 | 2023-03-20 | 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 | 2023-02-07 | 2023-03-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-07 | 2023-03-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-07 | 2023-03-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-31 | 2023-03-14 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-31 | 2023-03-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-31 | 2023-03-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-31 | 2023-03-14 | 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 | 2023-01-31 | 2023-03-14 | 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 | 2023-01-31 | 2023-03-14 | 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 | 2023-01-31 | 2023-03-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-25 | 2022-04-08 | 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 | 2022-02-25 | 2022-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-25 | 2022-04-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-25 | 2022-04-08 | N |
| Meet other general requirements. | Fire Safety | 2022-03-03 | 2022-04-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-03 | 2022-04-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-03 | 2022-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-03 | 2022-04-07 | N |
