A list of the most recent deficiencies for Sunset Villa Healthcare. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-02 | 2023-03-03 | 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 | 2023-02-02 | 2023-03-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-02 | 2023-03-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-02 | 2023-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-02 | 2023-03-03 | N |
| 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 | 2023-02-02 | 2023-03-03 | N |
| Post nurse staffing information every day. | Health | 2023-02-02 | 2023-03-03 | 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 | 2023-02-02 | 2023-03-03 | 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 | 2023-02-02 | 2023-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-02 | 2023-03-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-02 | 2023-03-03 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-02-02 | 2023-03-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-02 | 2023-03-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-26 | 2023-02-21 | 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 | 2023-01-26 | 2023-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-01-26 | 2022-02-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-01-26 | 2022-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-26 | 2022-02-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-01-26 | 2022-02-18 | N |
| Post nurse staffing information every day. | Health | 2022-01-26 | 2022-02-18 | 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 | 2022-01-26 | 2022-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-18 | 2022-02-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-01-18 | 2022-02-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-18 | 2022-02-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-02 | 2021-07-01 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-12-15 | 2021-01-21 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2020-12-15 | 2021-01-21 | 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 | 2020-12-15 | 2021-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-12-15 | 2021-01-21 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2020-12-15 | 2021-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-12-15 | 2021-01-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-12-15 | 2021-01-21 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-12-08 | 2021-01-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-12-08 | 2021-01-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-12-08 | 2021-01-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-12-08 | 2021-01-21 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2020-12-08 | 2021-01-21 | N |
