A list of the most recent deficiencies for Villa Maria Post Acute. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-09 | 2024-01-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-22 | 2023-07-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-22 | 2023-07-22 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-22 | 2023-07-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-22 | 2023-07-22 | 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 | 2023-06-22 | 2023-07-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-22 | 2023-07-22 | 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 | 2023-06-22 | 2023-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-22 | 2023-07-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-27 | 2023-07-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-27 | 2023-07-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-27 | 2023-07-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-27 | 2023-07-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-26 | 2023-05-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-13 | 2022-06-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-16 | 2022-01-03 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-09-02 | 2021-09-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-10 | 2021-05-25 | 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 | 2020-01-10 | 2020-02-18 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-01-10 | 2020-02-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-10 | 2020-02-18 | 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 | 2020-01-10 | 2020-02-11 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2020-01-10 | 2020-02-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-23 | 2020-02-11 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2020-01-10 | 2020-02-07 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-01-10 | 2020-02-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-10 | 2020-02-04 | 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 | 2020-01-10 | 2020-02-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-10 | 2020-02-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-01-10 | 2020-02-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-03-07 | 2019-04-02 | 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 | 2019-03-07 | 2019-04-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-07 | 2019-04-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-11 | 2019-02-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-01-11 | 2019-02-21 | 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 | 2019-01-11 | 2019-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-11 | 2019-02-21 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2019-01-11 | 2019-02-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-11 | 2019-02-21 | N |
