A list of the most recent deficiencies for Sgmc Health Villa. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-12 | 2023-03-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-12 | 2023-03-29 | N |
| Provide or obtain dental services for each resident. | Health | 2023-02-12 | 2023-03-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-12 | 2023-03-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-12 | 2023-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-12 | 2023-03-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-12 | 2023-03-29 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-13 | 2023-03-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-19 | 2021-12-03 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-08-13 | 2021-09-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-13 | 2021-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-13 | 2021-09-24 | 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 | 2021-08-13 | 2021-09-24 | 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 | 2021-08-13 | 2021-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-13 | 2021-09-24 | N |
| Dispose of garbage and refuse properly. | Health | 2021-08-13 | 2021-09-24 | 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 | 2021-08-13 | 2021-09-24 | 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 | 2021-08-13 | 2021-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-13 | 2021-09-24 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-13 | 2021-09-24 | 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 | 2021-08-13 | 2021-09-24 | 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 | 2018-09-09 | 2018-10-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-09-09 | 2018-10-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-09-09 | 2018-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-09 | 2018-10-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-09 | 2018-10-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-09 | 2018-10-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-09 | 2018-10-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-09 | 2018-10-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-09 | 2018-10-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-09-09 | 2018-10-24 | N |
| Have proper openings in smoke barrier doors. | Fire Safety | 2018-09-09 | 2018-10-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-09 | 2018-10-24 | N |
