THE VILLAGES OF LAPEER NURSING & REHABILITATION

Nursing Home Inspector

239 S MAIN ST
LAPEER, MI 48446
Lapeer County
Phone: 810-664-6611
Provider Number: 235654
Last Inspection: 03/01/2017

About the Nursing Home

Number of Beds: 87
Number of Residents: 66
Beds Available: 21
Percent Occupancy: 76%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

52

Facility
23

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

52

2017
13

2016
20

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/1/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 4/10/2017
 
Failed To: Send unopened mail from residents and promptly deliver unopened mail to residents. Isolated : Minimal 3 4/10/2017
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 4/10/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 4/10/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 4/10/2017
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Pattern : Minimal 4 4/10/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 4/10/2017
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 4/10/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 4/10/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 4/10/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 4/10/2017
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 4/10/2017
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 4/10/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 4/10/2017
 

4/21/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 5/31/2016
 
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 5/31/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/31/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 5/31/2016
 

5/14/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 6/23/2015
 
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Pattern : Minimal 4 6/23/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/23/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 6/23/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/23/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

5/24/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/2/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 7/2/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 7/2/2017
 

1/7/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Potential 3 unknown
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 66 89.50 85.64
Registered Nurses 0.51 1.19 0.89
Licensed Practical / Vocational Nurses 1.07 1.11 0.84
Certified Nursing Assistants 2.05 2.30 2.54
Total Staff Hours 3.63 4.60 4.27

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MI State Avg%
of high risk long-stay residents with pressure ulcers 9 9 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 98 96 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 83 92
of long-stay residents experiencing one or more falls with major injury 4 3 3
of long-stay residents who have depressive symptoms 6 2 2
of long-stay residents who lose too much weight 7 6 7
of long-stay residents who received an antianxiety or hypnotic medication 19 24 22
of long-stay residents who received an antipsychotic medication 26 17 12
of long-stay residents who self-report moderate to severe pain 8 7 6
of long-stay residents who were physically restrained 3 2 0
of long-stay residents whose ability to move independently worsened 13 15 17
of long-stay residents whose need for help with daily activities has increased 11 15 14
of long-stay residents with a catheter inserted and left in their bladder 0 2 2
of long-stay residents with a urinary tract infection 7 3 3
of low risk long-stay residents who lose control of their bowels or bladder 51 46 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 92 89 80
of short-stay residents who had an outpatient emergency department visit 5 10 11
of short-stay residents who made improvements in function 66 67 71
of short-stay residents who newly received an antipsychotic medication 0 1 1
of short-stay residents who self-report moderate to severe pain 29 20 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88 87 79
of short-stay residents who were rehospitalized after a nursing home admission 23 23 21
of short-stay residents who were successfully discharged to the community 38 57 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0