Deficiency Records for St. Joseph Villa Nursing Center
Updated as of February 01, 2022
This is not the most recent data for St. Joseph Villa Nursing Center. For the most recent information, click here.
A list of the most recent deficiencies for St. Joseph Villa Nursing 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? |
|---|---|---|---|---|
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-01-19 | 2021-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-01-19 | 2021-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-13 | 2021-03-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-01-13 | 2021-03-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-01-13 | 2021-03-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-01-13 | 2021-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-10 | 2020-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-10 | 2020-09-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-20 | 2019-07-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-20 | 2019-07-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-16 | 2019-07-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-16 | 2019-07-05 | 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 | 2019-05-16 | 2019-07-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-16 | 2019-07-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-05-16 | 2019-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-16 | 2019-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-16 | 2019-07-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-16 | 2019-07-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-05-16 | 2019-07-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-16 | 2019-07-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-06 | 2019-07-03 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-21 | 2019-07-02 | 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 | 2019-05-21 | 2019-07-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-21 | 2019-07-02 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2019-05-21 | 2019-07-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-21 | 2019-07-02 | 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 | 2019-05-21 | 2019-07-02 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-05-21 | 2019-07-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-21 | 2019-07-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-21 | 2019-07-02 | 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 | 2019-05-21 | 2019-07-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-21 | 2019-07-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-21 | 2019-07-02 | 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 | 2019-05-21 | 2019-07-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-21 | 2019-07-02 | 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 | 2019-05-21 | 2019-07-02 | N |
| Provide or obtain dental services for each resident. | Health | 2019-05-21 | 2019-07-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-21 | 2019-07-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-04-01 | 2019-05-03 | Y |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-02-06 | 2018-04-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-02-06 | 2018-04-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-12 | 2018-03-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-12 | 2018-03-08 | 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 | 2018-02-12 | 2018-03-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-12 | 2018-03-08 | N |
| Respond appropriately to all alleged violations. | Health | 2018-02-12 | 2018-03-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-02-12 | 2018-03-08 | 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 | 2018-02-12 | 2018-03-08 | 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 | 2018-02-12 | 2018-03-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-12 | 2018-03-08 | N |
| Provide activities to meet all resident's needs. | Health | 2018-02-12 | 2018-03-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-12 | 2018-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-12 | 2018-03-08 | 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 | 2018-02-12 | 2018-03-08 | 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 | 2018-02-12 | 2018-03-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-02-12 | 2018-03-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-12 | 2018-03-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-02-12 | 2018-03-08 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-02-12 | 2018-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-12 | 2018-03-08 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2018-02-12 | 2018-03-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-02-06 | 2018-03-08 | 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 | 2018-02-06 | 2018-03-08 | 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 | 2018-02-06 | 2018-03-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-06 | 2018-03-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-02-06 | 2018-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-06 | 2018-03-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-02-06 | 2018-03-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-02-06 | 2018-03-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-02-06 | 2018-03-08 | N |
