A list of the most recent deficiencies for Villa Manor Care 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? |
|---|---|---|---|---|
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-10 | 2024-10-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-10 | 2024-02-02 | 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 | 2024-01-10 | 2024-02-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-10 | 2024-02-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-10 | 2024-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-10 | 2024-02-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-10 | 2024-02-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-10 | 2024-02-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-10 | 2024-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-10 | 2024-02-02 | N |
| 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 | 2024-01-10 | 2024-02-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-14 | 2024-01-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-14 | 2024-01-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-12-14 | 2024-01-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-14 | 2024-01-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-14 | 2024-01-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-14 | 2024-01-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-14 | 2024-01-19 | 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 | 2023-12-14 | 2024-01-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-14 | 2024-01-19 | 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 | 2023-12-14 | 2024-01-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-12-14 | 2024-01-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-11 | 2023-11-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-11 | 2023-11-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-20 | 2022-11-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-20 | 2022-11-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-09-20 | 2022-10-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-20 | 2022-10-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-02 | 2022-10-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-02 | 2022-10-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-02 | 2022-10-18 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-20 | 2022-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-20 | 2022-10-07 | 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 | 2019-09-12 | 2019-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-12 | 2019-10-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-12 | 2019-10-20 | 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 | 2019-09-12 | 2019-10-20 | 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 | 2019-09-12 | 2019-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-12 | 2019-10-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-10 | Not Fixed | N |
