A list of the most recent deficiencies for St Joseph's, A Villa 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? |
|---|---|---|---|---|
| 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 | 2023-11-29 | 2023-12-15 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-11-29 | 2023-12-15 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-11-29 | 2023-12-15 | 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 | 2023-11-29 | 2023-12-15 | Y |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-11-27 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-27 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-27 | 2023-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-27 | 2023-12-15 | 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 | 2022-09-13 | 2022-10-05 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-13 | 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 | 2022-09-13 | 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 | 2022-09-13 | 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 | 2022-09-13 | 2022-10-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-09-13 | 2022-10-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-13 | 2022-10-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-13 | 2022-10-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-13 | 2022-10-05 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-12 | 2022-10-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-29 | 2022-05-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-26 | 2021-06-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-26 | 2021-06-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-26 | 2021-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-26 | 2021-06-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-26 | 2021-06-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-26 | 2021-06-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-05-26 | 2021-06-25 | 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 | 2021-05-26 | 2021-06-25 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-05-26 | 2021-06-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-26 | 2021-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-26 | 2021-06-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-26 | 2021-06-25 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-05-26 | 2021-06-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-26 | 2021-06-25 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-05-26 | 2021-06-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-26 | 2021-06-25 | Y |
| 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 | 2021-05-26 | 2021-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-26 | 2021-06-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-26 | 2021-06-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-26 | 2021-06-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-26 | 2021-06-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-26 | 2021-06-25 | N |
