Deficiency Records for Victoria Falls
Updated as of March 01, 2021
This is not the most recent data for Victoria Falls. For the most recent information, click here.
A list of the most recent deficiencies for Victoria Falls. 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 safe and appropriate respiratory care for a resident when needed. | Health | 2020-06-23 | 2020-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-06-23 | 2020-09-10 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2020-08-06 | 2020-09-10 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2020-08-06 | 2020-09-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2020-08-06 | 2020-09-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-08-06 | 2020-09-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-08-06 | 2020-09-10 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-08-06 | 2020-09-10 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-08-06 | 2020-09-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2020-08-06 | 2020-09-10 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-08-06 | 2020-09-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-08-06 | 2020-09-10 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-08-06 | 2020-09-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-08-06 | 2020-09-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-06 | 2020-09-10 | Y |
| 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 | 2020-08-06 | 2020-09-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-08-06 | 2020-09-10 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2020-08-06 | 2020-09-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-08-06 | 2020-09-10 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-08-06 | 2020-09-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-08-06 | 2020-09-10 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-08-06 | 2020-09-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-06 | 2020-09-10 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-04 | 2020-03-05 | 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 | 2020-02-04 | 2020-03-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Be properly staffed | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-04 | 2020-03-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-12 | 2019-09-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-17 | 2019-09-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-12 | 2019-09-03 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-14 | 2019-03-29 | 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 | 2019-03-14 | 2019-03-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-14 | 2019-03-29 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-03-06 | 2019-03-29 | 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 | 2019-03-06 | 2019-03-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-06 | 2019-03-29 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-06 | 2019-03-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-06 | 2019-03-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-06 | 2019-03-29 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-03-06 | 2019-03-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-06 | 2019-03-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-06 | 2019-03-29 | 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 | 2019-03-06 | 2019-03-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-06 | 2019-03-29 | 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 | 2019-03-06 | 2019-03-29 | 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 | 2019-03-06 | 2019-03-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-03-06 | 2019-03-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-21 | 2018-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-21 | 2018-04-25 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2018-03-21 | 2018-04-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-21 | 2018-04-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-21 | 2018-04-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-21 | 2018-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-21 | 2018-04-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-03-21 | 2018-04-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-21 | 2018-04-25 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-03-21 | 2018-04-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-21 | 2018-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-21 | 2018-04-25 | Y |
| 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 | 2018-03-21 | 2018-04-25 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-03-21 | 2018-04-25 | 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 | 2018-03-21 | 2018-04-25 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-03-21 | 2018-04-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-21 | 2018-04-25 | Y |
| 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 | 2018-03-21 | 2018-04-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-03-21 | 2018-04-25 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-07-10 | 2017-08-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-07-10 | 2017-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-10 | 2017-07-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-07-10 | 2017-07-19 | 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 | 2017-07-10 | 2017-07-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-07-10 | 2017-07-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-07-10 | 2017-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-10 | 2017-07-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-07-10 | 2017-07-14 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-07-10 | 2017-07-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-07-10 | 2017-07-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-07-10 | 2017-07-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-07-10 | 2017-07-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-07-10 | 2017-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-07-10 | 2017-07-13 | N |
| Use approved construction type or materials. | Fire Safety | 2017-07-10 | 2017-07-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-07-10 | 2017-07-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-17 | Not Fixed | N |
