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 |