A list of the most recent deficiencies for Villa Toscana at Cypress Woods. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-01 | 2023-12-04 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-01 | 2023-12-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-01 | 2023-12-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-01 | 2023-12-04 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-01 | 2023-12-04 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-01 | 2023-12-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-01 | 2023-12-04 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-01 | 2023-12-04 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-12-01 | 2023-12-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-01 | 2023-12-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-01 | 2023-12-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2023-12-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2023-12-04 | Y |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-11-30 | 2023-12-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-30 | 2023-12-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-30 | 2023-12-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-30 | 2023-08-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-30 | 2023-08-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-30 | 2023-08-31 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-21 | 2022-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-21 | 2022-10-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-21 | 2022-10-15 | 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 | 2022-09-21 | 2022-10-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-20 | 2022-09-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-14 | 2021-12-15 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-14 | 2021-12-15 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-23 | 2021-08-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-23 | 2021-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-23 | 2021-08-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-23 | 2021-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-23 | 2021-08-15 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-07-22 | 2021-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-22 | 2021-08-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-22 | 2021-08-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-22 | 2021-08-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-19 | 2021-04-15 | Y |
