A list of the most recent deficiencies for North Village 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? |
|---|---|---|---|---|
| Provide activities to meet all resident's needs. | Health | 2023-11-20 | 2024-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2024-01-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-20 | 2024-01-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-20 | 2024-01-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-11-20 | 2024-01-24 | 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 | 2023-11-20 | 2024-01-24 | N |
| 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 | 2023-11-20 | 2024-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-20 | 2024-01-24 | N |
| Dispose of garbage and refuse properly. | Health | 2023-11-20 | 2024-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-20 | 2024-01-24 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2023-11-20 | 2024-01-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-20 | 2024-01-24 | Y |
| 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 | 2023-11-20 | 2024-01-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-20 | 2024-01-24 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-20 | 2024-01-24 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2023-11-20 | 2024-01-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-20 | 2024-01-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-20 | 2024-01-24 | 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 | 2023-11-20 | 2024-01-24 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-11-30 | 2024-01-24 | 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 | 2023-11-30 | 2024-01-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-30 | 2024-01-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-23 | 2023-10-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-20 | 2023-06-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-24 | 2023-06-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-24 | 2023-06-27 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-24 | 2023-06-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-17 | 2023-03-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-29 | 2022-11-23 | Y |
| 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 | 2022-09-06 | 2022-11-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-06 | 2022-10-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-06 | 2022-10-18 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-06 | 2022-10-18 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-06-24 | 2022-08-23 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-06-02 | 2022-05-25 | Y |
| Provide immediate access to any resident. | Health | 2022-03-22 | 2022-05-24 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-03-22 | 2022-05-24 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-03-22 | 2022-05-24 | Y |
| 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 | 2022-03-22 | 2022-05-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-22 | 2022-05-24 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-03-22 | 2022-05-24 | Y |
| 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 | 2022-03-22 | 2022-05-24 | Y |
| Provide immediate access to any resident. | Health | 2021-12-22 | 2022-05-24 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-12-22 | 2022-05-24 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-12-22 | 2022-05-24 | Y |
| 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 | 2021-12-22 | 2022-05-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-22 | 2022-05-24 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-12-22 | 2022-05-24 | Y |
| 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 | 2021-12-22 | 2022-05-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-01 | 2021-10-01 | Y |
| 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 | 2021-04-15 | 2021-09-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-15 | 2021-09-24 | Y |
| 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 | 2021-04-15 | 2021-09-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-15 | 2021-09-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-15 | 2021-09-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-15 | 2021-09-24 | 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 | 2021-04-15 | 2021-09-24 | 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 | 2021-04-15 | 2021-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-09-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-14 | 2021-09-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-27 | 2021-09-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-27 | 2021-09-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-27 | 2021-09-24 | 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 | 2021-07-27 | 2021-09-24 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-04-15 | 2021-09-24 | N |
| 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 | 2021-04-15 | 2021-09-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-15 | 2021-09-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-15 | 2021-09-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-01 | 2021-08-04 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-04-15 | 2021-07-05 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-04-15 | 2021-07-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-04-15 | 2021-07-05 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-04-15 | 2021-07-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-15 | 2021-07-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-04-15 | 2021-07-05 | 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 | 2021-04-15 | 2021-07-05 | 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 | 2021-04-15 | 2021-07-05 | 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 | 2021-04-15 | 2021-07-05 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-04-15 | 2021-07-05 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-04-15 | 2021-07-05 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-04-15 | 2021-07-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-15 | 2021-07-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-04-15 | 2021-07-05 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2021-04-15 | 2021-07-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-15 | 2021-07-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-15 | 2021-07-05 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-04-15 | 2021-07-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-04-15 | 2021-07-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-15 | 2021-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-15 | 2021-07-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-04-15 | 2021-07-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-15 | 2021-07-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-15 | 2021-07-05 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-04-15 | 2021-07-05 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-04-15 | 2021-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-15 | 2021-07-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-15 | 2021-07-05 | 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 | 2021-04-15 | 2021-07-05 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-04-15 | 2021-07-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-15 | 2021-07-05 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-15 | 2021-07-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-15 | 2021-07-05 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-04-15 | 2021-07-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-15 | 2021-07-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-15 | 2021-07-05 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-04-15 | 2021-07-05 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Meet other general requirements. | Fire Safety | 2021-04-15 | 2021-07-05 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2019-11-22 | 2020-01-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-22 | 2020-01-06 | 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 | 2019-11-22 | 2020-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-22 | 2020-01-06 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-11-22 | 2020-01-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-22 | 2020-01-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-22 | 2020-01-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-11-22 | 2020-01-06 | N |
