A list of the most recent deficiencies for The Pavilion at Villa Pueblo. 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? |
|---|---|---|---|---|
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-14 | 2024-01-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-14 | 2024-01-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-14 | 2024-01-11 | 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 | 2023-12-14 | 2024-01-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-14 | 2024-01-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-14 | 2024-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-11 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-08-09 | 2023-09-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-09 | 2023-09-06 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-09 | 2023-09-06 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-21 | 2022-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-21 | 2022-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-21 | 2022-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-21 | 2022-12-15 | 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 | 2022-09-01 | 2022-10-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-01 | 2022-10-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-01 | 2022-10-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-01 | 2022-10-01 | 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 | 2022-09-01 | 2022-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-01 | 2022-10-01 | 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 | 2022-09-01 | 2022-10-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-01 | 2022-10-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-01 | 2022-10-01 | 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 | 2022-09-01 | 2022-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-01 | 2022-10-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-23 | 2021-07-29 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-06-23 | 2021-07-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-23 | 2021-07-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-23 | 2021-07-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-23 | 2021-07-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-23 | 2021-06-28 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2021-06-23 | 2021-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-23 | 2021-06-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-23 | 2021-06-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-09 | 2021-06-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-09 | 2021-06-13 | N |
