A list of the most recent deficiencies for Villa Health Care Center. 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 residents' personal and medical records private and confidential. | Health | 2023-06-26 | 2023-07-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-26 | 2023-07-14 | Y |
| 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 | 2022-10-03 | 2022-10-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-30 | 2021-09-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-13 | 2021-08-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-02 | 2021-07-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-02 | 2021-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-02 | 2021-07-26 | 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 | 2021-07-02 | 2021-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-02 | 2021-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-02 | 2021-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-02 | 2021-07-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-02 | 2021-07-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-02 | 2021-07-26 | 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 | 2021-07-02 | 2021-07-26 | 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 | 2021-07-02 | 2021-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-02 | 2021-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-02 | 2021-07-26 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-07-02 | 2021-07-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-10-17 | 2019-11-04 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-10-17 | 2019-11-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-17 | 2019-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-17 | 2019-11-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-17 | 2019-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-17 | 2019-11-04 | 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 | 2019-09-19 | 2019-10-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-09-19 | 2019-10-14 | 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 | 2019-09-19 | 2019-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-19 | 2019-10-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-19 | 2019-10-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-19 | 2019-10-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-09-19 | 2019-10-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-19 | 2019-10-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-01-09 | 2019-01-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-01-09 | 2019-01-29 | N |
| Develop a communication plan. | Fire Safety | 2019-01-09 | 2019-01-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-01-09 | 2019-01-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-09 | 2019-01-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-09 | 2019-01-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-09 | 2019-01-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-09 | 2019-01-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-02 | 2018-11-29 | 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 | 2018-11-02 | 2018-11-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-02 | 2018-11-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-02 | 2018-11-29 | 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 | 2018-11-02 | 2018-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-02 | 2018-11-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-11-02 | 2018-11-29 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-07 | Not Fixed | N |
