A list of the most recent deficiencies for Villa Elena Healthcare 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-23 | 2024-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-23 | 2024-03-23 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-22 | 2024-02-26 | 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 | 2024-01-22 | 2024-02-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-01-22 | 2024-02-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-22 | 2024-02-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-22 | 2024-02-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-22 | 2024-02-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-22 | 2024-02-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-22 | 2024-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-22 | 2024-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-22 | 2024-02-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-19 | 2024-02-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-19 | 2024-02-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-19 | 2024-02-21 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-19 | 2024-02-21 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-19 | 2024-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-19 | 2024-02-21 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-19 | 2024-02-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-19 | 2024-02-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-19 | 2024-02-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-19 | 2024-02-21 | N |
| 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 | 2024-01-19 | 2024-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-19 | 2024-02-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-19 | 2024-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-19 | 2024-02-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-19 | 2024-02-21 | N |
| Keep all essential equipment working safely. | Health | 2024-01-19 | 2024-02-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-01-19 | 2024-02-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-19 | 2024-02-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-03 | 2024-01-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-03 | 2024-01-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-03 | 2024-01-02 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-12-03 | 2024-01-02 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-03 | 2024-01-02 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-12-03 | 2024-01-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-04 | 2023-12-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-04 | 2023-12-20 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-04 | 2023-12-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-04 | 2023-12-20 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-12-04 | 2023-12-20 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-27 | 2023-11-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-17 | 2023-03-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-17 | 2023-03-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-17 | 2023-03-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-17 | 2023-03-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-17 | 2023-03-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-17 | 2023-03-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-17 | 2023-03-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-17 | 2023-03-18 | 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 | 2023-02-17 | 2023-03-18 | N |
| 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 | 2023-02-17 | 2023-03-18 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-02-17 | 2023-03-18 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-02-17 | 2023-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-17 | 2023-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-17 | 2023-03-18 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-02-13 | 2023-03-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-13 | 2023-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-22 | 2023-01-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-12-22 | 2023-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-16 | 2023-01-06 | 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 | 2022-11-15 | 2022-12-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-15 | 2022-12-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-01 | 2022-11-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-05 | 2022-07-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-15 | 2022-06-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-15 | 2022-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-05 | 2022-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-16 | 2022-04-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-16 | 2022-04-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-16 | 2022-04-15 | 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 | 2022-02-18 | 2022-03-09 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-02-18 | 2022-03-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-31 | 2022-02-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-09 | 2020-02-20 | 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 | 2020-01-09 | 2020-02-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-09 | 2020-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-02-20 | 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 | 2020-01-09 | 2020-02-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-09 | 2020-02-20 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2020-01-09 | 2020-02-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-09 | 2020-02-20 | 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 | 2020-01-09 | 2020-02-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-09 | 2020-02-20 | 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 | 2020-01-09 | 2020-02-20 | 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 | 2020-01-09 | 2020-02-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-09 | 2020-02-20 | 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 | 2020-01-09 | 2020-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-20 | N |
| Keep all essential equipment working safely. | Health | 2020-01-09 | 2020-02-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-08 | 2020-02-06 | N |
| Construct fire resistant interior walls. | Fire Safety | 2020-01-08 | 2020-02-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-08 | 2020-02-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-08 | 2020-02-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-08 | 2020-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | Not Fixed | Y |
