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Deficiency Records for The Villas at Poway
A list of the most recent deficiencies for The Villas at Poway. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Villas at Poway. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-10-21 | 2024-10-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-10-21 | 2024-10-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-10-21 | 2024-10-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-06 | 2024-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-28 | 2024-01-16 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-18 | 2023-09-30 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-23 | 2023-05-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-23 | 2023-05-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-23 | 2023-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-23 | 2023-05-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-23 | 2023-05-15 | N |
| Dispose of garbage and refuse properly. | Health | 2023-03-23 | 2023-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-05-15 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-23 | 2023-05-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-23 | 2023-05-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-23 | 2023-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-23 | 2023-05-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-23 | 2023-05-15 | 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 | 2023-03-23 | 2023-05-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-23 | 2023-05-15 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-03-23 | 2023-05-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-23 | 2023-05-15 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-23 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-28 | 2023-04-19 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-03-28 | 2023-04-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-28 | 2023-04-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-28 | 2023-04-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-28 | 2023-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-28 | 2023-04-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-28 | 2023-04-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-28 | 2023-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-02-26 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-02-05 | 2020-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-05 | 2020-02-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-05 | 2020-02-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-30 | 2020-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-30 | 2020-02-24 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-01-30 | 2020-02-24 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2020-01-30 | 2020-02-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-30 | 2020-02-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-30 | 2020-02-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-01-16 | 2019-02-27 | N |
| Use approved construction type or materials. | Fire Safety | 2019-01-16 | 2019-02-27 | 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 | 2019-01-16 | 2019-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-16 | 2019-02-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-16 | 2019-02-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-14 | 2019-01-31 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-12-14 | 2019-01-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-14 | 2019-01-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-14 | 2019-01-31 | N |
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