A list of the most recent deficiencies for Concordia at Villa St Joseph. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-26 | 2023-11-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-26 | 2023-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-03 | 2023-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-06-16 | 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 | 2023-05-03 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-03 | 2023-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-27 | 2022-11-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-27 | 2022-11-28 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-07-29 | 2022-08-26 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-29 | 2022-08-26 | 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 | 2022-07-29 | 2022-08-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-29 | 2022-08-26 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-07-29 | 2022-08-26 | 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 | 2022-07-29 | 2022-08-26 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-05-27 | 2022-07-05 | N |
| 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 | 2022-05-27 | 2022-07-05 | N |
| 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 | 2022-05-27 | 2022-07-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-27 | 2022-07-05 | 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 | 2022-05-27 | 2022-07-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-26 | 2022-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-26 | 2022-07-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-26 | 2022-07-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-26 | 2022-07-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-16 | 2022-04-22 | Y |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-11-19 | 2020-12-18 | N |
