A list of the most recent deficiencies for Ponderosa Villa. 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-07 | 2023-12-15 | 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 | 2023-11-07 | 2023-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-07 | 2023-12-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-02 | 2023-11-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-02 | 2023-11-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-02 | 2023-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-15 | 2022-11-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-15 | 2022-11-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-06-22 | 2021-08-06 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-22 | 2021-08-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-22 | 2021-08-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-06-22 | 2021-08-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-22 | 2021-08-06 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-06-22 | 2021-08-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-22 | 2021-08-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-22 | 2021-08-06 | N |
