A list of the most recent deficiencies for Village Health Care 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-24 | 2023-05-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-24 | 2023-05-05 | 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 | 2023-02-24 | 2023-05-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-24 | 2023-05-05 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-02-24 | 2023-05-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-24 | 2023-05-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-24 | 2023-05-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-24 | 2023-05-05 | 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 | 2023-02-24 | 2023-05-05 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-04-28 | 2023-05-04 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-02-24 | 2023-04-20 | N |
| 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 | 2023-02-24 | 2023-04-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-24 | 2023-04-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-24 | 2023-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-24 | 2023-04-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-24 | 2023-04-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-24 | 2023-04-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-02-24 | 2023-04-20 | 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 | 2023-02-24 | 2023-04-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-24 | 2023-04-20 | 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 | 2023-02-24 | 2023-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-24 | 2023-04-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-02-24 | 2023-04-20 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-02-24 | 2023-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-24 | 2023-04-20 | Y |
| 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 | 2023-02-24 | 2023-04-20 | Y |
| 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 | 2023-02-24 | 2023-04-20 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-08 | 2023-04-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-08 | 2023-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-21 | 2019-10-30 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-08-21 | 2019-10-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-21 | 2019-10-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-21 | 2019-10-30 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-08-21 | 2019-10-30 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-08-21 | 2019-10-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-21 | 2019-10-30 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-14 | 2019-10-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-08-14 | 2019-10-10 | 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 | 2019-08-14 | 2019-10-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-08-14 | 2019-10-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-06-12 | 2018-08-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-12 | 2018-08-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-06-12 | 2018-08-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-06-12 | 2018-08-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-06-12 | 2018-08-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-12 | 2018-08-15 | N |
| Respond appropriately to all alleged violations. | Health | 2018-06-12 | 2018-08-15 | 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 | 2018-06-12 | 2018-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-12 | 2018-08-15 | N |
