Deficiency Records for St. Joseph Villa Nursing Center
Updated as of March 01, 2023
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? |
|---|---|---|---|---|
| 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 | 2022-06-14 | 2022-07-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-06-14 | 2022-07-07 | 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 | 2022-06-14 | 2022-07-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-14 | 2022-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-14 | 2022-07-07 | 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 | 2022-06-13 | 2022-07-07 | 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 | 2022-06-13 | 2022-07-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-06-13 | 2022-07-07 | N |
| 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 requirements for the use and maintenance of medical gas equipment. | 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 |
| 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 requirements for the use and maintenance of medical gas equipment. | 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 |
| 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 |
