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Deficiency Records for Lakeridge Villa Health Care Center

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.

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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-05-07 2024-05-17 Y
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2024-05-07 2024-05-17 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-05-07 2024-05-17 Y
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
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

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