A list of the most recent deficiencies for Villa Del Rio Gardens. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-10 | 2022-03-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-10 | 2022-03-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-10 | 2022-03-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-10 | 2022-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-10 | 2022-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-10 | 2022-03-24 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-02-10 | 2022-03-24 | 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 | 2022-02-10 | 2022-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-10 | 2022-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-03-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-20 | 2021-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-31 | 2021-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-25 | 2021-06-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-14 | 2019-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-14 | 2019-09-18 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-08-14 | 2019-09-18 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-08-14 | 2019-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-14 | 2019-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-14 | 2019-09-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-14 | 2019-09-18 | N |
| Keep all essential equipment working safely. | Health | 2019-08-14 | 2019-09-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-14 | 2019-09-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-15 | 2019-09-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-08-15 | 2019-09-09 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-08-15 | 2019-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-15 | 2019-09-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-01 | 2018-08-31 | 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 | 2018-08-01 | 2018-08-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-01 | 2018-08-31 | 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 | 2018-08-01 | 2018-08-31 | 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 | 2018-08-01 | 2018-08-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-01 | 2018-08-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-01 | 2018-08-31 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2018-08-01 | 2018-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-01 | 2018-08-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-07-31 | 2018-08-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-07-31 | 2018-08-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-07-31 | 2018-08-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-31 | 2018-08-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-31 | 2018-08-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-07-31 | 2018-08-28 | N |
