Deficiency Records for The Village at Northrise - Desert Willow I
Updated as of March 01, 2024
A list of the most recent deficiencies for The Village at Northrise - Desert Willow I. 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? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-06 | 2023-12-21 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-06 | 2023-12-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-06 | 2023-12-21 | 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 | 2023-11-06 | 2023-12-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-06 | 2023-12-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-06 | 2023-12-21 | N |
| 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 | 2023-11-06 | 2023-12-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-06 | 2023-12-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-06 | 2023-12-21 | 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 | 2023-11-06 | 2023-12-21 | 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 | 2023-11-06 | 2023-12-21 | 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 | 2023-11-06 | 2023-12-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-06 | 2023-12-21 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-11-06 | 2023-12-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-06 | 2023-12-21 | 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 | 2023-11-06 | 2023-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-06 | 2023-12-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-06 | 2023-12-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-12 | 2023-03-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-12 | 2023-03-24 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-12 | 2023-03-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-12 | 2023-03-24 | 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 | 2023-01-12 | 2023-03-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-12 | 2023-03-24 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-01-12 | 2023-03-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-12 | 2023-03-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-12 | 2023-03-24 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-12 | 2023-03-24 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-12 | 2023-03-24 | 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 | 2023-01-12 | 2023-03-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-12 | 2023-03-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-12 | 2023-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-03 | 2023-02-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-21 | 2022-04-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-21 | 2022-04-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-21 | 2022-04-05 | 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 | 2022-02-21 | 2022-04-05 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-21 | 2022-04-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-21 | 2022-04-05 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-21 | 2022-04-05 | 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 | 2022-02-21 | 2022-04-05 | 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 | 2022-02-21 | 2022-04-05 | 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 | 2022-02-21 | 2022-04-05 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-02-21 | 2022-04-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-21 | 2022-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-21 | 2022-04-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-21 | 2022-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-21 | 2022-04-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-02-21 | 2022-04-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-21 | 2022-04-05 | N |
| Report COVID19 data to residents and families. | Health | 2022-02-21 | 2022-04-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-21 | 2022-04-05 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-02-21 | 2022-04-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-08 | 2022-04-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-08 | 2022-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-08 | 2022-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-22 | 2021-11-17 | N |
