Deficiency Records for Village Healthcare and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Village Healthcare and Rehabilitation. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-02 | 2023-10-27 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-08 | 2022-12-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-08 | 2022-12-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-08 | 2022-12-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-11-11 | Y |
| 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 | 2021-09-29 | 2021-10-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-29 | 2021-10-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-29 | 2021-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-29 | 2021-10-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-29 | 2021-10-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-29 | 2021-10-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-01 | 2021-10-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-01 | 2021-10-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-01 | 2021-10-02 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-10-01 | 2021-10-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-01 | 2021-10-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-01 | 2021-10-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-29 | 2021-10-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-06 | 2020-03-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-06 | 2020-03-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-06 | 2020-03-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-06 | 2020-03-06 | 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 | 2020-02-06 | 2020-03-06 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-06 | 2020-03-06 | 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 | 2020-02-06 | 2020-03-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-06 | 2020-03-06 | 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 | 2020-02-06 | 2020-03-06 | 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 | 2020-02-06 | 2020-03-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-06 | 2020-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-02-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-05 | 2020-02-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-29 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-05 | Not Fixed | N |
