A list of the most recent deficiencies for Del Rosa 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? |
|---|---|---|---|---|
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-01-16 | 2024-02-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-16 | 2024-02-05 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-01-16 | 2024-02-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-16 | 2024-02-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-16 | 2024-02-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-16 | 2024-02-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-16 | 2024-02-05 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-12-13 | 2024-01-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-13 | 2024-01-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-13 | 2024-01-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-13 | 2024-01-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-13 | 2024-01-08 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-12-13 | 2024-01-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-13 | 2024-01-08 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-12-13 | 2024-01-08 | 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 | 2023-12-13 | 2024-01-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-13 | 2024-01-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-13 | 2024-01-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2024-01-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-13 | 2024-01-08 | 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 | 2023-06-20 | 2023-07-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-09 | 2023-01-12 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-08-12 | 2022-08-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-06 | 2022-08-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-03 | 2022-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-27 | 2022-01-12 | 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 | 2021-11-02 | 2021-11-22 | 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 | 2021-11-02 | 2021-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-02 | 2021-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-02 | 2021-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-21 | 2021-11-12 | 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 | 2021-10-21 | 2021-11-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-21 | 2021-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2021-11-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-19 | 2021-06-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-19 | 2021-06-04 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-02-28 | 2020-03-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-28 | 2020-03-30 | N |
| 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 | 2020-02-28 | 2020-03-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-28 | 2020-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-28 | 2020-03-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-26 | 2020-03-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-26 | 2020-03-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-02-26 | 2020-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-26 | 2020-03-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-26 | 2020-03-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-26 | 2020-03-16 | N |
