Deficiency Records for Villa Maria Nursing and Rehabilitation Community
Updated as of April 01, 2024
A list of the most recent deficiencies for Villa Maria Nursing and Rehabilitation Community. 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-20 | 2023-12-11 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-09-20 | 2023-12-11 | Y |
| 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 | 2023-09-20 | 2023-12-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-20 | 2023-12-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-20 | 2023-12-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-09-20 | 2023-12-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-09-20 | 2023-12-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-20 | 2023-12-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-20 | 2023-12-11 | 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 | 2023-09-20 | 2023-12-11 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-20 | 2023-12-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-20 | 2023-12-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-20 | 2023-12-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-20 | 2023-12-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-20 | 2023-12-11 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-20 | 2023-12-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-20 | 2023-12-11 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-09-20 | 2023-12-11 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-09-20 | 2023-12-11 | 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 | 2023-09-20 | 2023-12-11 | 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 | 2023-09-20 | 2023-12-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-20 | 2023-12-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-09-20 | 2023-12-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-20 | 2023-12-11 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-09-20 | 2023-12-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-20 | 2023-12-11 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-20 | 2023-12-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-20 | 2023-12-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-12-11 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-09-20 | 2023-12-11 | 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 | 2023-09-20 | 2023-12-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-13 | 2023-11-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-13 | 2023-11-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-13 | 2023-11-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-13 | 2023-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-13 | 2023-11-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-13 | 2023-11-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-13 | 2023-11-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-13 | 2023-11-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-27 | 2021-11-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-27 | 2021-11-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-27 | 2021-11-26 | Y |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-08-04 | 2021-10-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-10 | 2021-09-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-10 | 2021-09-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-10 | 2021-09-21 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-10 | 2021-09-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-08-10 | 2021-09-21 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-08-10 | 2021-09-21 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-08-10 | 2021-09-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-10 | 2021-09-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-10 | 2021-09-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-10 | 2021-09-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-26 | 2019-06-01 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-26 | 2019-06-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-26 | 2019-06-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-26 | 2019-06-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-26 | 2019-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-26 | 2019-06-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-25 | 2019-05-14 | N |
