A list of the most recent deficiencies for Epworth Villa Health Services. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-11 | 2023-09-18 | 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 | 2023-08-11 | 2023-09-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-11 | 2023-09-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-26 | 2022-08-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-26 | 2022-08-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-26 | 2022-08-25 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-19 | 2022-08-25 | 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 | 2022-07-19 | 2022-08-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-19 | 2022-08-25 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-02-05 | 2019-03-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-01 | 2019-03-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-02-05 | 2019-02-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-05 | 2019-02-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-05 | 2019-02-28 | 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 | 2019-02-05 | 2019-02-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-05 | 2019-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-05 | 2019-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-05 | 2019-02-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-05 | 2019-02-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-02-05 | 2019-02-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-02-01 | 2019-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-01 | 2019-02-21 | 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 | 2019-02-01 | 2019-02-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-01 | 2019-02-11 | 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 | 2017-10-25 | 2017-11-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-10-25 | 2017-11-03 | N |
