A list of the most recent deficiencies for Miravilla 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-01-22 | 2024-02-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-10 | 2022-12-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-10 | 2022-12-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-10 | 2022-12-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-10 | 2022-12-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-10 | 2022-12-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-10 | 2022-12-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-11-10 | 2022-12-07 | 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 | 2022-11-10 | 2022-12-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-10 | 2022-12-07 | 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 | 2022-11-10 | 2022-12-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-10 | 2022-12-07 | N |
| Dispose of garbage and refuse properly. | Health | 2022-11-10 | 2022-12-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-10 | 2022-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-31 | 2022-09-21 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-06-03 | 2022-06-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-03 | 2022-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-24 | 2022-06-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-22 | 2022-04-26 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-10 | 2022-04-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-07 | 2022-01-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-08 | 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 | 2021-07-21 | 2021-08-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-25 | 2021-07-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-25 | 2021-07-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-19 | 2021-05-11 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-19 | 2019-10-07 | 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 | 2019-08-09 | 2019-09-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-09 | 2019-09-19 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-08-09 | 2019-09-19 | 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 | 2019-08-09 | 2019-09-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-09 | 2019-09-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-09 | 2019-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-09 | 2019-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-09 | 2019-09-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-08-09 | 2019-09-19 | 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 | 2019-08-09 | 2019-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-09 | 2019-09-19 | N |
| Develop a communication plan. | Fire Safety | 2018-10-24 | 2018-11-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-24 | 2018-11-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-24 | 2018-11-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-24 | 2018-11-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-24 | 2018-11-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-10-24 | 2018-11-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-24 | 2018-11-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-09 | 2018-08-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-09 | 2018-08-13 | N |
| 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 | 2018-08-09 | 2018-08-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-08-09 | 2018-08-13 | 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 | 2018-08-09 | 2018-08-13 | 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 | 2018-08-09 | 2018-08-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-08-09 | 2018-08-13 | N |
