A list of the most recent deficiencies for Villa Del Rio. 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 | 2023-09-28 | 2023-10-27 | 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 | 2023-07-06 | 2023-07-27 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-23 | 2023-07-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-28 | 2023-07-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-28 | 2023-07-21 | Y |
| Post nurse staffing information every day. | Health | 2023-04-10 | 2023-04-18 | Y |
| 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 | 2022-12-22 | 2023-01-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-18 | 2022-03-28 | 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 |
| 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 |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Install corridor and hallway doors that block smoke. | 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 |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-16 | 2022-03-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-11 | 2022-03-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-11 | 2022-03-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-11 | 2022-03-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-11 | 2022-03-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-11 | 2022-03-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-11 | 2022-03-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-11 | 2022-03-08 | 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 | 2022-02-11 | 2022-03-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-11 | 2022-03-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-11 | 2022-03-08 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-02-11 | 2022-03-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-11 | 2022-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-08 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-02-11 | 2022-03-08 | 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 | 2021-09-21 | 2021-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-21 | 2021-10-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-23 | 2021-09-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-23 | 2021-08-09 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-23 | 2021-08-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-15 | 2019-09-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-15 | 2019-09-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-15 | 2019-09-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-15 | 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 | 2019-08-15 | 2019-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-09-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-08-15 | 2019-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-15 | 2019-09-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-15 | 2019-09-19 | 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 | 2019-08-15 | 2019-09-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-15 | 2019-09-19 | 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 | 2019-08-15 | 2019-09-19 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-08-15 | 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 | 2019-08-15 | 2019-09-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-15 | 2019-09-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-15 | 2019-09-09 | 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 | 2018-08-02 | 2018-08-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-08-02 | 2018-08-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-02 | 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 | 2018-08-02 | 2018-08-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-02 | 2018-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-02 | 2018-08-31 | 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 | 2018-08-02 | 2018-08-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-02 | 2018-08-31 | 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 | 2018-08-02 | 2018-08-31 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-08-02 | 2018-08-31 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-08-02 | 2018-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-02 | 2018-08-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-02 | 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 |
| Inspect, test, and maintain automatic sprinkler systems. | 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 |
