A list of the most recent deficiencies for Snf-The Villa at Marymount. 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-20 | 2024-03-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-20 | 2024-03-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-20 | 2024-03-13 | Y |
| 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 | 2023-11-30 | 2023-12-05 | Y |
| 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 | 2023-11-08 | 2023-12-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-30 | 2023-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2023-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2023-12-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-28 | 2023-12-05 | 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 | 2023-11-28 | 2023-12-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-28 | 2023-12-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-08 | 2023-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-11-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-11 | 2022-07-22 | Y |
| 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 | 2022-07-11 | 2022-07-22 | Y |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2021-06-09 | 2021-09-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-06-09 | 2021-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-04 | 2021-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-04 | 2021-07-20 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-09 | 2021-07-20 | 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 | 2021-06-09 | 2021-07-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Have enough space near smoke barriers to protect residents. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-06-09 | 2021-07-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-15 | 2021-06-04 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-16 | 2019-08-01 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2019-01-16 | 2019-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-16 | 2019-08-01 | 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 | 2019-01-16 | 2019-03-08 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-01-16 | 2019-03-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-01-16 | 2019-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-16 | 2019-03-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-16 | 2019-03-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-01-16 | 2019-03-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-16 | 2019-03-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-16 | 2019-03-08 | N |
