Deficiency Records for Mountain Villa Nursing Center
Updated as of May 01, 2021
This is not the most recent data for Mountain Villa Nursing Center. For the most recent information, click here.
A list of the most recent deficiencies for Mountain Villa Nursing 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? |
|---|---|---|---|---|
| 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 | 2020-11-25 | 2020-12-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-11-25 | 2020-12-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-27 | 2020-03-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-27 | 2020-03-18 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-01-10 | 2020-02-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-19 | 2019-08-30 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-11 | 2019-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-11 | 2019-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-08-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-11 | 2019-08-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-11 | 2019-08-25 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2019-07-11 | 2019-08-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-11 | 2019-08-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-11 | 2019-08-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-11 | 2019-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-11 | 2019-08-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-11 | 2019-08-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-11 | 2019-08-25 | 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 | 2019-07-11 | 2019-08-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-11 | 2019-08-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-11 | 2019-08-25 | 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 | 2019-07-11 | 2019-08-25 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-07-11 | 2019-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-08-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-07-11 | 2019-08-25 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-07-11 | 2019-08-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Develop a communication plan. | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-19 | 2018-08-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-20 | 2018-08-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-07-20 | 2018-08-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-20 | 2018-08-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-20 | 2018-08-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-20 | 2018-08-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-07-20 | 2018-08-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-05-01 | 2018-05-31 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-07-13 | 2017-08-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-13 | 2017-08-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-07-13 | 2017-08-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-13 | 2017-08-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-07-13 | 2017-08-28 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-07-14 | 2017-08-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-07-14 | 2017-08-28 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-14 | 2017-08-28 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-07-14 | 2017-08-28 | N |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2017-07-14 | 2017-08-28 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-14 | 2017-08-28 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-07-14 | 2017-08-28 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-07-14 | 2017-08-28 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-07-14 | 2017-08-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-07-14 | 2017-08-28 | N |
