A list of the most recent deficiencies for The Villa at Silverbell Estates. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-06-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-08 | 2023-06-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-08 | 2023-06-20 | 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 | 2023-06-08 | 2023-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-06-20 | 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 | 2023-06-08 | 2023-06-20 | 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 | 2023-06-08 | 2023-06-20 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-06-08 | 2023-06-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-08 | 2023-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-06-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-08 | 2023-06-20 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-12 | 2023-06-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-27 | 2023-05-25 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-10 | 2023-05-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-27 | 2023-05-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-27 | 2023-05-10 | 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 | 2023-04-27 | 2023-05-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-27 | 2023-05-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-27 | 2023-05-10 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-03-30 | 2022-04-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-30 | 2022-04-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-30 | 2022-04-29 | 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 | 2022-03-30 | 2022-04-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-30 | 2022-04-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-30 | 2022-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-30 | 2022-04-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-17 | 2021-12-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-17 | 2021-12-04 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-06-24 | 2021-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-23 | 2021-05-19 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2021-04-23 | 2021-05-14 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-04-23 | 2021-05-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-05-14 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-23 | 2021-05-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-05 | 2021-04-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-05 | 2021-03-29 | N |
| 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 | 2021-03-05 | 2021-03-29 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-03-05 | 2021-03-29 | 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 | 2021-03-05 | 2021-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-05 | 2021-03-29 | 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 | 2021-03-05 | 2021-03-29 | 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 | 2021-03-05 | 2021-03-29 | 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 | 2021-03-05 | 2021-03-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-03-05 | 2021-03-29 | 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 | 2021-03-05 | 2021-03-29 | 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 | 2021-03-05 | 2021-03-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-05 | 2021-03-29 | 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 | 2021-03-05 | 2021-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-05 | 2021-03-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-03-05 | 2021-03-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-03-05 | 2021-03-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-04 | 2021-03-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-04 | 2021-03-29 | 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 | 2021-03-04 | 2021-03-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-03-04 | 2021-03-29 | N |
