A list of the most recent deficiencies for Villa Gardens Health Care Unit. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-31 | 2024-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-03-01 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-17 | 2023-11-09 | 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 | 2023-10-17 | 2023-11-09 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-08 | 2023-10-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-08 | 2023-10-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-08 | 2023-10-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-08 | 2023-10-30 | 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 | 2023-10-08 | 2023-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-08 | 2023-10-30 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-08 | 2023-10-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-08 | 2023-10-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-10-08 | 2023-10-30 | 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 | 2023-08-24 | 2023-09-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-24 | 2023-09-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-23 | 2022-11-29 | 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 | 2022-10-23 | 2022-11-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-23 | 2022-11-29 | 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 | 2022-10-23 | 2022-11-29 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-10-23 | 2022-11-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-23 | 2022-11-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-10-23 | 2022-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-23 | 2022-11-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-23 | 2022-11-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-23 | 2022-11-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-23 | 2022-11-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-23 | 2022-11-29 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-10-23 | 2022-11-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-23 | 2022-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-23 | 2022-11-29 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-23 | 2022-11-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-23 | 2022-11-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-10-23 | 2022-11-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-08-18 | 2019-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-18 | 2019-09-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-18 | 2019-09-09 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-08-08 | 2019-09-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-08 | 2019-09-06 | 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 | 2019-08-08 | 2019-09-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-08 | 2019-09-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-08 | 2019-09-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-08 | 2019-09-06 | 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 | 2019-08-08 | 2019-09-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-08 | 2019-09-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-08 | 2019-09-06 | N |
