A list of the most recent deficiencies for The Villa at The Park. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-07 | 2023-11-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-26 | 2023-10-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-19 | 2023-08-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-19 | 2023-08-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-19 | 2023-08-11 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-07-19 | 2023-08-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-07-19 | 2023-08-11 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-07-19 | 2023-08-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-19 | 2023-08-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-19 | 2023-08-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-19 | 2023-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-08-11 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-07-19 | 2023-08-11 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-19 | 2023-08-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-19 | 2023-08-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-19 | 2023-08-11 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-19 | 2023-08-11 | 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 | 2023-07-19 | 2023-08-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-19 | 2023-08-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-19 | 2023-08-11 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-07-19 | 2023-08-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-19 | 2023-08-11 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-04-17 | 2023-05-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-17 | 2023-05-26 | 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 | 2023-04-17 | 2023-05-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-12 | 2022-06-20 | N |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2022-05-12 | 2022-06-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-12 | 2022-06-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-12 | 2022-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-12 | 2022-06-20 | 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 | 2022-05-12 | 2022-06-20 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-05-12 | 2022-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-12 | 2022-06-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-12 | 2022-06-20 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-12 | 2022-06-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-12 | 2022-06-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-05-12 | 2022-06-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-12 | 2022-06-20 | 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 | 2022-05-12 | 2022-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-06-20 | 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 | 2022-05-12 | 2022-06-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-12 | 2022-06-20 | 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 | 2022-05-11 | 2022-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-06 | 2021-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-21 | 2021-04-28 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-03-08 | 2021-03-23 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-03-08 | 2021-03-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-08 | 2021-03-23 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-03-08 | 2021-03-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-02-24 | 2021-03-22 | 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 | 2021-02-24 | 2021-03-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-02-24 | 2021-03-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-02-24 | 2021-03-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-24 | 2021-03-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-24 | 2021-03-22 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-02-24 | 2021-03-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-02-24 | 2021-03-22 | N |
| Post nurse staffing information every day. | Health | 2021-02-24 | 2021-03-22 | 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 | 2021-02-24 | 2021-03-22 | 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 | 2021-02-24 | 2021-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-24 | 2021-03-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-02-24 | 2021-03-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-02-24 | 2021-03-22 | N |
