Deficiency Records for Villa Maria Post Acute and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Villa Maria Post Acute and Rehabilitation. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-15 | 2023-11-18 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-09-15 | 2023-11-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-09-15 | 2023-11-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-15 | 2023-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-15 | 2023-11-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-15 | 2023-11-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-15 | 2023-11-18 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-15 | 2023-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-15 | 2023-11-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-26 | 2023-05-29 | 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 | 2023-05-26 | 2023-05-27 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-11 | 2022-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-11 | 2022-09-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-11 | 2022-09-30 | 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 | 2022-08-11 | 2022-09-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-11 | 2022-09-30 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-08-11 | 2022-09-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-11 | 2022-09-30 | Y |
| 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 | 2022-08-11 | 2022-09-26 | 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 | 2022-08-11 | 2022-09-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-11 | 2022-09-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-19 | 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 | 2020-10-30 | 2020-12-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-10-30 | 2020-12-14 | N |
| 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 | 2020-10-30 | 2020-12-14 | 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 | 2020-10-30 | 2020-12-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-30 | 2020-12-14 | N |
| Post nurse staffing information every day. | Health | 2020-10-30 | 2020-12-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide or obtain dental services for each resident. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-30 | 2020-12-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-10-30 | 2020-12-08 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-10-30 | 2020-12-08 | N |
