A list of the most recent deficiencies for Villa Del Sol 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? |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-11-05 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-10-23 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-27 | 2023-10-17 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-24 | 2023-09-23 | Y |
Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable. | Health | 2023-08-24 | 2023-09-23 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-28 | 2023-08-18 | 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 | 2023-07-14 | 2023-08-05 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-14 | 2023-08-05 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-23 | 2023-06-20 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-11 | 2023-06-10 | Y |
Ensure each resident receives an accurate assessment. | Health | 2023-05-11 | 2023-06-10 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-11 | 2023-06-10 | 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 | 2023-05-11 | 2023-06-10 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-06-10 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-05 | 2023-06-06 | Y |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-25 | 2023-05-25 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-24 | 2023-05-25 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-24 | 2023-05-25 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-30 | 2023-02-03 | Y |
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-05-20 | 2022-06-23 | Y |
Ensure staff are vaccinated for COVID-19 | Health | 2022-05-10 | 2022-05-20 | Y |
Ensure staff are vaccinated for COVID-19 | Health | 2022-04-05 | 2022-04-08 | 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 | 2022-01-13 | 2022-01-21 | Y |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-29 | 2021-06-02 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-29 | 2021-06-02 | 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 | 2021-04-29 | 2021-06-02 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-04-29 | 2021-06-02 | 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 | 2021-04-29 | 2021-06-02 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-29 | 2021-06-02 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-29 | 2021-06-02 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-29 | 2021-06-02 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-29 | 2021-06-02 | N |
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 | 2021-04-29 | 2021-06-02 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-29 | 2021-06-02 | 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 | 2021-04-29 | 2021-06-02 | 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 | 2021-04-29 | 2021-06-02 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-29 | 2021-06-02 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-29 | 2021-06-02 | N |
Provide and implement an infection prevention and control program. | Health | 2021-04-29 | 2021-06-02 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-04-29 | 2021-06-01 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-29 | 2021-06-01 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-29 | 2021-06-01 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-29 | 2021-06-01 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-29 | 2021-06-01 | 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 | 2019-08-30 | 2019-10-01 | 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 | 2019-08-30 | 2019-10-01 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-30 | 2019-10-01 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-30 | 2019-10-01 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-30 | 2019-10-01 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-30 | 2019-10-01 | N |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-08-30 | 2019-10-01 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-30 | 2019-10-01 | 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 | 2019-08-30 | 2019-10-01 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-30 | 2019-10-01 | 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 | 2019-08-30 | 2019-10-01 | N |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-08-30 | 2019-10-01 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-30 | 2019-10-01 | N |
Provide and implement an infection prevention and control program. | Health | 2019-08-30 | 2019-10-01 | N |
Construct fire resistant interior walls. | Fire Safety | 2019-08-23 | 2019-09-16 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2019-08-23 | 2019-09-16 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-23 | 2019-09-16 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-23 | 2019-09-16 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-23 | 2019-09-16 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-20 | 2018-09-18 | N |
Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-08-20 | 2018-09-18 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-20 | 2018-09-18 | 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 | 2018-08-20 | 2018-09-18 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-20 | 2018-09-18 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-20 | 2018-09-18 | 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 | 2018-08-20 | 2018-09-18 | N |
Provide and implement an infection prevention and control program. | Health | 2018-08-20 | 2018-09-18 | N |
Have power receptacles that are properly grounded. | Fire Safety | 2018-08-22 | 2018-09-18 | N |