A list of the most recent deficiencies for Addolorata 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-25 | 2023-09-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-13 | 2023-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-06-21 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-02 | 2023-03-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-02 | 2023-03-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-02 | 2023-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-02 | 2023-03-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-02 | 2023-03-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-02 | 2023-03-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-02 | 2023-03-17 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-03-02 | 2023-03-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-03-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-16 | 2023-03-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-16 | 2023-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-16 | 2023-03-08 | 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 | 2023-02-16 | 2023-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-03-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-06-20 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-04-27 | 2022-05-20 | 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 | 2022-04-27 | 2022-05-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-27 | 2022-05-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-15 | 2022-05-05 | 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 | 2022-04-15 | 2022-05-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-15 | 2022-05-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-15 | 2022-05-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-15 | 2022-05-05 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-04-15 | 2022-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-28 | 2022-03-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-28 | 2022-03-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-16 | 2021-10-10 | 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 | 2021-08-16 | 2021-10-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-16 | 2021-10-10 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2020-09-29 | 2020-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-29 | 2020-11-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-09-29 | 2020-11-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-09-29 | 2020-11-13 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-09-29 | 2020-11-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-09-29 | 2020-11-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-09-29 | 2020-11-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-09-29 | 2020-11-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-09-29 | 2020-11-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-09-29 | 2020-11-02 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-09-29 | 2020-11-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-09-29 | 2020-10-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-01 | 2020-10-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-09-29 | 2020-10-23 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-09-29 | 2020-10-23 | N |
