Deficiency Records for The Villa at City Center
Updated as of October 01, 2023
This is not the most recent data for The Villa at City Center. For the most recent information, click here.
A list of the most recent deficiencies for The Villa at City Center. 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 necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-05-23 | 2023-05-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-02 | 2023-03-21 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-26 | 2023-02-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-16 | 2022-12-23 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-08-31 | 2022-10-05 | N |
| 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 | 2022-08-31 | 2022-10-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-31 | 2022-10-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-31 | 2022-10-05 | 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 | 2022-08-31 | 2022-10-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-31 | 2022-10-05 | 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 | 2022-08-31 | 2022-10-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-31 | 2022-10-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-31 | 2022-10-05 | 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 | 2022-08-31 | 2022-10-05 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-31 | 2022-10-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-31 | 2022-10-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-31 | 2022-10-05 | 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 | 2022-08-31 | 2022-10-05 | 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 | 2022-08-31 | 2022-10-05 | 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 | 2022-08-31 | 2022-10-05 | N |
| Post nurse staffing information every day. | Health | 2022-08-31 | 2022-10-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-31 | 2022-10-05 | 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 | 2022-08-31 | 2022-10-05 | 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 | 2022-08-31 | 2022-10-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-31 | 2022-10-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-31 | 2022-10-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-08-10 | 2022-09-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-10 | 2022-09-02 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-03-17 | 2022-03-25 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-03-17 | 2022-03-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-03-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-10 | 2022-02-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-10 | 2022-02-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-17 | 2021-09-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-19 | 2021-07-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-23 | 2021-07-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-05 | 2021-04-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-31 | 2021-04-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-01-06 | 2021-02-05 | 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 | 2020-01-09 | 2020-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-02-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-09 | 2020-02-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-09 | 2020-02-14 | 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 | 2020-01-09 | 2020-02-14 | N |
| Post nurse staffing information every day. | Health | 2020-01-09 | 2020-02-14 | 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 | 2020-01-09 | 2020-02-14 | 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 | 2020-01-09 | 2020-02-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-09 | 2020-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-09 | 2020-02-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-25 | 2018-12-14 | 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 | 2018-10-25 | 2018-12-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-10-25 | 2018-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-25 | 2018-11-23 | N |
| 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 | 2018-10-25 | 2018-11-23 | 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 | 2018-10-25 | 2018-11-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-25 | 2018-11-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2018-11-23 | N |
