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Deficiency Records for Virgil Rehabilitation and Skilled Nursing Center
A list of the most recent deficiencies for Virgil Rehabilitation and Skilled Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Virgil Rehabilitation and Skilled 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? |
|---|---|---|---|---|
| Meet other general requirements that are deficient. | Fire Safety | 2024-01-04 | 2024-02-04 | 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 | 2024-01-04 | 2024-02-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-04 | 2024-02-04 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-01-04 | 2024-02-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-04 | 2024-02-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-04 | 2024-02-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-04 | 2024-02-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-04 | 2024-02-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-04 | 2024-02-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-29 | 2024-01-29 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-12-29 | 2024-01-29 | 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 | 2023-12-29 | 2024-01-29 | N |
| 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 | 2023-12-29 | 2024-01-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-12-29 | 2024-01-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-29 | 2024-01-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-29 | 2024-01-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-29 | 2024-01-29 | N |
| Post nurse staffing information every day. | Health | 2023-12-29 | 2024-01-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-29 | 2024-01-29 | 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 | 2023-12-29 | 2024-01-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-29 | 2024-01-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-29 | 2024-01-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-29 | 2024-01-29 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-12-29 | 2024-01-29 | 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 | 2023-08-01 | 2023-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-07 | 2023-07-06 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-07 | 2023-07-06 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-06-07 | 2023-07-06 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-06-07 | 2023-07-06 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-06-07 | 2023-07-06 | Y |
| 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 | 2023-03-16 | 2023-04-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-16 | 2023-04-14 | N |
| 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 | 2023-03-16 | 2023-04-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-16 | 2023-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-16 | 2023-04-14 | 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 | 2023-03-16 | 2023-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-04-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-03-16 | 2023-04-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-16 | 2023-04-14 | 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 | 2023-03-16 | 2023-04-14 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-03-16 | 2023-04-14 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-03-16 | 2023-04-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-16 | 2023-04-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| 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 | 2023-03-15 | 2023-04-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-15 | 2023-04-07 | 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 | 2023-03-15 | 2023-04-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-15 | 2023-04-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-06 | 2023-03-31 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-03-06 | 2023-03-31 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-01 | 2023-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-01 | 2023-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-09 | 2022-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-11 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-09-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-29 | 2022-08-05 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| 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 | 2019-12-22 | 2020-01-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-22 | 2020-01-30 | 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 | 2019-12-22 | 2020-01-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-22 | 2020-01-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-22 | 2020-01-22 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-12-22 | 2020-01-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-22 | 2020-01-22 | N |
| 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 | 2019-12-22 | 2020-01-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-22 | 2020-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-22 | 2020-01-22 | 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 | 2019-12-22 | 2020-01-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-22 | 2020-01-22 | N |
| 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 | 2019-12-22 | 2020-01-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-22 | 2020-01-22 | 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 | 2019-12-22 | 2020-01-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-22 | 2020-01-22 | 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 | 2019-12-22 | 2020-01-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-22 | 2020-01-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-12-22 | 2020-01-22 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-12-22 | Not Fixed | N |
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