A list of the most recent deficiencies for St Dominic Villa. 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? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-06 | 2023-10-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-06 | 2023-10-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-06 | 2023-10-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-06 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-06 | 2023-10-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-06 | 2023-10-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-10-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-06 | 2023-10-30 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-06 | 2023-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-06 | 2023-10-30 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-19 | 2023-05-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-19 | 2023-05-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-19 | 2023-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-19 | 2023-05-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-19 | 2023-05-19 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-18 | 2023-05-19 | 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 | 2023-04-18 | 2023-05-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-18 | 2023-05-19 | 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 | 2023-04-18 | 2023-05-19 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-04-18 | 2023-05-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-18 | 2023-05-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-18 | 2023-05-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-08 | 2022-04-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-08 | 2022-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-08 | 2022-04-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-08 | 2022-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-08 | 2022-04-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-08 | 2022-04-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-08 | 2022-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-08 | 2022-04-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-08 | 2022-04-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-08 | 2022-04-21 | N |
| Report COVID19 data to residents and families. | Health | 2022-03-08 | 2022-04-21 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-08 | 2022-04-21 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-08 | 2022-04-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-08 | 2022-04-21 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-08 | 2022-04-21 | Y |
| Post nurse staffing information every day. | Health | 2022-03-08 | 2022-04-21 | Y |
| 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 | 2022-03-03 | 2022-04-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-03 | 2022-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-03 | 2022-04-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-03 | 2022-04-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-03 | 2022-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-03 | 2022-04-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-03 | 2022-04-21 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-03-03 | 2022-04-21 | N |
| Respond appropriately to all alleged violations. | Health | 2021-03-17 | 2021-04-17 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2020-01-22 | 2020-02-22 | 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 | 2020-01-22 | 2020-02-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-22 | 2020-02-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-13 | 2020-02-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-01-13 | 2020-02-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-13 | 2020-02-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-13 | 2020-02-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-13 | 2020-02-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | Not Fixed | Y |
