A list of the most recent deficiencies for The Villa at Rose City. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-14 | 2023-04-14 | 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 | 2023-03-14 | 2023-04-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-14 | 2023-04-14 | 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 | 2023-03-14 | 2023-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-14 | 2023-04-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-14 | 2023-04-14 | 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 | 2023-03-14 | 2023-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-14 | 2023-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-14 | 2023-04-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-14 | 2023-04-14 | 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 | 2023-03-09 | 2023-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-09 | 2023-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-07 | 2023-02-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-28 | 2022-04-14 | 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 | 2022-03-28 | 2022-04-14 | Y |
| Post nurse staffing information every day. | Health | 2022-03-28 | 2022-04-14 | Y |
| 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 | 2022-03-28 | 2022-04-14 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-28 | 2022-04-14 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-30 | 2022-01-04 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-11-30 | 2021-12-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-30 | 2021-12-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-06 | 2021-12-23 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-06 | 2021-12-23 | 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 | 2021-12-06 | 2021-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-06 | 2021-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-06 | 2021-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-06 | 2021-12-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-06 | 2021-12-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-06 | 2021-12-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-17 | 2021-09-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-18 | 2021-07-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-18 | 2021-07-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-18 | 2021-07-16 | 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 | 2021-06-18 | 2021-07-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-29 | 2021-05-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-29 | 2021-05-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-31 | 2019-11-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-31 | 2019-11-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-11-25 | 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 | 2019-10-31 | 2019-11-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-31 | 2019-11-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-31 | 2019-11-25 | N |
| Post nurse staffing information every day. | Health | 2019-10-31 | 2019-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-11-25 | 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 | 2019-10-30 | 2019-11-25 | 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 | 2019-10-30 | 2019-11-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-30 | 2019-11-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-30 | 2019-11-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-30 | 2019-11-25 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-10-30 | 2019-11-25 | N |
