Deficiency Records for The Villa at Parkridge
Updated as of January 01, 2023
This is not the most recent data for The Villa at Parkridge. For the most recent information, click here.
A list of the most recent deficiencies for The Villa at Parkridge. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-17 | 2022-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-05 | 2022-09-01 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-05 | 2022-09-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-05 | 2022-09-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-05 | 2022-09-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-05 | 2022-09-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-08-05 | 2022-09-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-05 | 2022-09-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-05 | 2022-09-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-05 | 2022-09-01 | 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 | 2022-08-05 | 2022-09-01 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-05 | 2022-09-01 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-05 | 2022-09-01 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-08-05 | 2022-09-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-05 | 2022-09-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-05 | 2022-09-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-05 | 2022-09-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-05 | 2022-09-01 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-05 | 2022-09-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-05 | 2022-09-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-05 | 2022-09-01 | 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 | 2022-08-05 | 2022-09-01 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-05 | 2022-09-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-05 | 2022-09-01 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-03 | 2022-09-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-03 | 2022-09-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-01 | 2022-06-09 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-02 | 2022-04-29 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-02-01 | 2022-04-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-01 | 2022-04-29 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-01 | 2022-04-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-02-01 | 2022-04-29 | 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 | 2022-02-01 | 2022-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-01 | 2022-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-01 | 2022-04-29 | Y |
| 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 | 2022-02-01 | 2022-03-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-01 | 2022-03-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-01 | 2022-03-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-01 | 2022-03-01 | 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 | 2022-02-01 | 2022-03-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-01 | 2022-03-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-02-01 | 2022-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-01 | 2022-03-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-01 | 2022-03-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-01 | 2022-03-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-02-01 | 2022-03-01 | 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 | 2022-02-01 | 2022-03-01 | 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 | 2022-02-01 | 2022-03-01 | 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 | 2022-02-01 | 2022-03-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-01 | 2022-03-01 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-02-01 | 2022-03-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-02-01 | 2022-03-01 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-02-01 | 2022-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-01 | 2022-03-01 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-02-01 | 2022-03-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-01 | 2022-03-01 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-02-01 | 2022-03-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-01 | 2022-03-01 | Y |
| 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 | 2022-01-13 | 2022-03-01 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-10-18 | 2021-11-03 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-10-18 | 2021-11-03 | Y |
| Provide or obtain dental services for each resident. | Health | 2021-10-18 | 2021-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-13 | 2021-08-05 | 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 | 2021-07-13 | 2021-08-05 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-26 | 2021-06-02 | Y |
| 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 | 2021-05-26 | 2021-06-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-26 | 2021-06-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-26 | 2021-06-02 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-26 | 2021-06-02 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-05-26 | 2021-06-02 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-07 | 2021-06-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-07 | 2021-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-07 | 2021-06-02 | 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 | 2021-04-07 | 2021-06-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-07 | 2021-05-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-04-07 | 2021-05-11 | 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 | 2021-04-07 | 2021-05-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-04-07 | 2021-05-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-04-07 | 2021-05-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-04-07 | 2021-05-11 | 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 | 2021-04-07 | 2021-05-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-07 | 2021-05-11 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-04-07 | 2021-05-11 | N |
| Provide activities to meet all resident's needs. | Health | 2021-04-07 | 2021-05-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-07 | 2021-05-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-07 | 2021-05-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-07 | 2021-05-11 | 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 | 2021-04-07 | 2021-05-11 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-04-07 | 2021-05-11 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-04-07 | 2021-05-11 | 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 | 2021-04-07 | 2021-05-11 | N |
| Provide or obtain dental services for each resident. | Health | 2021-04-07 | 2021-05-11 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-07 | 2021-05-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-07 | 2021-05-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-04-07 | 2021-05-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-07 | 2021-05-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-07 | 2021-05-11 | 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 | 2021-04-07 | 2021-05-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-07 | 2021-05-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-07 | 2021-05-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-07 | 2021-05-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-07 | 2021-05-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-07 | 2021-05-11 | 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 | 2021-04-07 | 2021-05-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-05-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-04 | 2021-03-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-01-25 | 2021-02-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-01-25 | 2021-02-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-08-25 | 2020-09-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-07-21 | 2020-09-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-07-21 | 2020-09-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-07-21 | 2020-09-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-07-21 | 2020-09-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-07-21 | 2020-09-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-07-21 | 2020-09-11 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2020-07-21 | 2020-09-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-07-21 | 2020-09-11 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2020-07-21 | 2020-09-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-07-21 | 2020-09-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-05-13 | 2020-06-11 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-01-10 | 2020-01-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-10 | 2020-01-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-10 | 2020-01-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-01-10 | 2020-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-10 | 2020-01-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-01-10 | 2020-01-31 | Y |
