A list of the most recent deficiencies for Saint Mary's Villa Nursing Hom. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-11-30 | 2024-01-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2024-01-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-30 | 2024-01-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-11-30 | 2024-01-30 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-11-30 | 2024-01-30 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-30 | 2024-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-01-30 | 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 | 2023-11-07 | 2024-01-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-07 | 2024-01-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-07 | 2024-01-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-07 | 2024-01-06 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-08 | 2023-01-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-08 | 2023-01-26 | 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 | 2022-12-08 | 2023-01-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-08 | 2023-01-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-08 | 2023-01-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-08 | 2023-01-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-02 | 2023-01-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-02 | 2023-01-19 | 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 | 2022-01-21 | 2022-03-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-21 | 2022-03-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-21 | 2022-03-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-01-21 | 2022-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-21 | 2022-03-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-21 | 2022-03-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-21 | 2022-03-17 | N |
| Use approved construction type or materials. | Fire Safety | 2022-01-12 | 2022-02-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-01-12 | 2022-02-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-12 | 2022-02-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-01-12 | 2022-02-28 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-01-12 | 2022-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-12 | 2022-02-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-20 | 2021-11-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-20 | 2021-11-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | Not Fixed | N |
