A list of the most recent deficiencies for Villa Marin. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-29 | 2023-09-28 | 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 | 2023-08-29 | 2023-09-28 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-29 | 2023-09-28 | 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 | 2023-08-18 | 2023-09-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-08-18 | 2023-09-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-18 | 2023-09-18 | 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 | 2023-08-18 | 2023-09-18 | N |
| 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 | 2023-08-18 | 2023-09-18 | 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 | 2023-08-18 | 2023-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-18 | 2023-09-18 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-08-18 | 2023-09-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-18 | 2023-09-18 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-05-15 | 2019-06-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-15 | 2019-06-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-15 | 2019-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-15 | 2019-06-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-15 | 2019-06-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-15 | 2019-06-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-15 | 2019-06-17 | 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 | 2019-03-01 | 2019-04-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-01 | 2019-04-18 | 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 | 2019-03-01 | 2019-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-01 | 2019-04-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-01 | 2019-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-01 | 2019-04-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-02-06 | 2018-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-06 | 2018-04-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-02-06 | 2018-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-06 | 2018-04-20 | N |
| Dispose of garbage and refuse properly. | Health | 2018-02-06 | 2018-04-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-02-06 | 2018-04-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-02-06 | 2018-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-06 | 2018-04-20 | N |
| Keep all essential equipment working safely. | Health | 2018-02-06 | 2018-04-20 | N |
| Develop a communication plan. | Fire Safety | 2018-02-13 | 2018-02-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-02-13 | 2018-02-26 | N |
