A list of the most recent deficiencies for Village Square Healthcare 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? |
|---|---|---|---|---|
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-11-03 | 2023-11-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-27 | 2023-07-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-29 | 2022-08-31 | 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 | 2022-07-29 | 2022-08-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-29 | 2022-08-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-29 | 2022-08-31 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-07-29 | 2022-08-31 | N |
| Post nurse staffing information every day. | Health | 2022-07-29 | 2022-08-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-29 | 2022-08-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-29 | 2022-08-31 | 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 | 2022-07-29 | 2022-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-29 | 2022-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-29 | 2022-08-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Use approved construction type or materials. | Fire Safety | 2022-08-02 | 2022-08-26 | 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 | 2022-08-02 | 2022-08-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-21 | 2022-08-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-14 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-06-12 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-11 | 2022-06-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-18 | 2022-05-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-12 | 2022-02-27 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-02 | 2021-12-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-15 | 2021-10-13 | 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 | 2021-09-21 | 2021-10-05 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-08-17 | 2021-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-25 | 2021-09-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-03 | 2021-06-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-21 | 2021-06-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-02 | 2021-04-20 | Y |
| 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 | 2019-04-08 | 2019-05-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-08 | 2019-05-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-08 | 2019-05-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-08 | 2019-05-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-08 | 2019-05-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-14 | 2019-04-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-14 | 2019-04-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-02-14 | 2019-04-25 | 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 | 2019-02-14 | 2019-04-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-14 | 2019-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-14 | 2019-04-25 | 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 | 2019-02-14 | 2019-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-14 | 2019-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-14 | 2019-04-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-14 | 2019-04-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-14 | 2019-04-25 | 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 | 2019-02-14 | 2019-04-25 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-02-14 | 2019-04-25 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-02-14 | 2019-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-14 | 2019-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-14 | 2019-02-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-02-14 | 2019-02-14 | N |
| 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 | 2018-03-01 | 2018-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-01 | 2018-04-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-01 | 2018-04-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-01 | 2018-04-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-01 | 2018-04-16 | 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 | 2018-03-01 | 2018-04-16 | 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 | 2018-03-01 | 2018-04-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-03-01 | 2018-04-16 | 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 | 2018-03-01 | 2018-04-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-03-01 | 2018-04-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-03-01 | 2018-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-01 | 2018-04-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-03-01 | 2018-04-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-03-01 | 2018-04-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-03-01 | 2018-04-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-03-21 | 2018-04-12 | N |
| Develop a communication plan. | Fire Safety | 2018-03-21 | 2018-04-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-03-21 | 2018-04-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-21 | 2018-04-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-03-21 | 2018-04-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-21 | 2018-04-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-03-21 | 2018-04-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-03-21 | 2018-04-12 | N |
