Deficiency Records for Village Creek Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Village Creek Nursing 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-14 | 2023-07-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-15 | 2023-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-15 | 2023-06-16 | 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 | 2023-06-15 | 2023-06-16 | 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 | 2023-06-15 | 2023-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-15 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-15 | 2023-06-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-14 | 2023-06-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-14 | 2023-06-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-20 | 2023-04-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-09 | 2022-08-11 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-06-29 | 2022-07-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-29 | 2022-07-25 | Y |
| Develop a communication plan. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-11 | 2022-06-17 | 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 | 2022-05-12 | 2022-06-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-12 | 2022-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-12 | 2022-06-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-12 | 2022-06-12 | 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 |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-11 | 2022-05-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-14 | 2021-08-06 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-03-10 | 2021-03-30 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-11 | 2020-01-17 | 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 | 2019-12-11 | 2020-01-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-12-12 | 2020-01-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-12-12 | 2020-01-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-12 | 2020-01-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-12 | 2020-01-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-12 | 2020-01-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-12 | 2020-01-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-12 | 2020-01-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-11 | 2019-05-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-12 | Not Fixed | N |
