A list of the most recent deficiencies for Mission Village Living Center, Inc. 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 | 2023-08-15 | 2023-10-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-15 | 2023-10-16 | N |
| 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 | 2023-08-15 | 2023-10-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-15 | 2023-10-16 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-08-15 | 2023-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-08 | 2023-09-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-08 | 2023-09-18 | 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 | 2023-08-08 | 2023-09-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-08 | 2023-09-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-15 | 2023-09-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-15 | 2023-09-12 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-15 | 2023-09-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-15 | 2023-09-12 | 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 | 2023-08-15 | 2023-09-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-15 | 2023-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-15 | 2023-09-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-15 | 2023-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-15 | 2023-09-12 | 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 | 2023-08-15 | 2023-09-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-15 | 2023-09-12 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-08-15 | 2023-09-12 | 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 | 2023-08-15 | 2023-09-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-08-15 | 2023-09-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-08-15 | 2023-09-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-15 | 2023-09-12 | 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 | 2023-08-15 | 2023-09-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-15 | 2023-09-12 | 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 | 2023-08-15 | 2023-09-12 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-08-15 | 2023-09-12 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-15 | 2023-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-15 | 2023-09-12 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-08-15 | 2023-09-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-15 | 2023-09-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-15 | 2023-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-15 | 2023-09-12 | 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 | 2023-06-14 | 2023-07-10 | 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 | 2023-06-14 | 2023-07-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-19 | 2022-11-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-19 | 2022-11-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-28 | 2022-05-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-19 | 2022-03-04 | 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 | 2022-01-19 | 2022-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-19 | 2022-03-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-13 | 2022-01-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-13 | 2022-01-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-13 | 2022-01-24 | 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 | 2021-12-13 | 2022-01-24 | 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 | 2021-12-13 | 2022-01-24 | 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 | 2021-12-13 | 2022-01-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-13 | 2022-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-13 | 2022-01-24 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-12-13 | 2022-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-19 | 2022-01-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-27 | 2022-01-14 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-06 | 2020-03-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-06 | 2020-03-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-06 | 2020-03-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-02-06 | 2020-03-16 | 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 | 2020-02-06 | 2020-03-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-06 | 2020-03-16 | 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 | 2020-02-06 | 2020-03-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-06 | 2020-03-16 | 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 | 2020-02-06 | 2020-03-16 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-02-06 | 2020-03-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-06 | 2020-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-06 | 2020-03-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-22 | 2020-02-21 | N |
