Deficiency Records for Marvistacountyvillahealthcare and wellnesscentre, LP
Updated as of April 01, 2024
A list of the most recent deficiencies for Marvistacountyvillahealthcare and wellnesscentre, LP. 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? |
|---|---|---|---|---|
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-02-06 | 2024-02-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-02 | 2024-02-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-21 | 2023-12-19 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-11-10 | 2023-12-10 | Y |
| 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 | 2023-11-10 | 2023-12-10 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-11-10 | 2023-12-10 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-10-10 | 2023-11-09 | 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 | 2023-10-10 | 2023-11-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-10 | 2023-11-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-06 | 2023-11-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-06 | 2023-11-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-06 | 2023-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-06 | 2023-11-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-06 | 2023-11-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-06 | 2023-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-06 | 2023-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-06 | 2023-11-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-26 | 2023-10-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-26 | 2023-10-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-24 | 2023-08-04 | 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 | 2023-06-22 | 2023-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-22 | 2023-07-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-05 | 2022-10-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-05 | 2022-10-27 | 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 | 2022-10-05 | 2022-10-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-10-05 | 2022-10-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-05 | 2022-10-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-05 | 2022-10-27 | 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 | 2022-10-05 | 2022-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2022-10-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-05 | 2022-10-27 | N |
| Post nurse staffing information every day. | Health | 2022-10-05 | 2022-10-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-05 | 2022-10-27 | 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 | 2022-10-05 | 2022-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-05 | 2022-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-05 | 2022-10-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-05 | 2022-10-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-06 | 2022-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-06 | 2022-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-06 | 2022-08-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-31 | 2022-06-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-25 | 2022-06-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-20 | 2022-06-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-19 | 2022-05-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-10 | 2022-05-27 | 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 | 2022-03-04 | 2022-03-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-06 | 2022-03-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-05 | 2022-03-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-31 | 2022-01-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-24 | 2022-01-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-13 | 2021-11-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-04 | 2021-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-11 | 2021-09-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-04 | 2021-09-20 | 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 | 2021-08-18 | 2021-09-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-30 | 2021-07-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-18 | 2021-06-25 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-15 | 2020-02-11 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2020-01-15 | 2020-02-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-15 | 2020-02-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-15 | 2020-02-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-09 | 2020-02-04 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-01-09 | 2020-02-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-02-04 | 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 | 2020-01-09 | 2020-02-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-09 | 2020-02-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-04 | 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 | 2020-01-09 | 2020-02-04 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-01-09 | 2020-02-04 | 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 | 2020-01-09 | 2020-02-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-09 | 2020-02-04 | 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 | 2020-01-09 | 2020-02-04 | 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 | 2020-01-09 | 2020-02-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-04 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2020-01-09 | 2020-02-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-02-04 | N |
| Keep all essential equipment working safely. | Health | 2020-01-09 | 2020-02-04 | 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 | 2022-02-03 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | Not Fixed | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-02-03 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-03 | Not Fixed | N |
