Deficiency Records for Villa Serena Healthcare Center
Updated as of August 01, 2024
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Deficiency Records for Villa Serena Healthcare Center
A list of the most recent deficiencies for Villa Serena Healthcare 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 Villa Serena Healthcare 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-31 | 2024-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-31 | 2024-06-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-06 | 2024-05-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-21 | 2024-02-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-21 | 2024-02-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-21 | 2024-02-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-21 | 2024-02-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-21 | 2024-02-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-01-21 | 2024-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-21 | 2024-02-20 | N |
| Keep all essential equipment working safely. | Health | 2024-01-21 | 2024-02-20 | 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 | 2024-01-21 | 2024-02-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-01-21 | 2024-02-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-22 | 2024-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-22 | 2024-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-17 | 2021-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-17 | 2021-12-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-17 | 2021-12-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-17 | 2021-12-14 | 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 | 2021-11-17 | 2021-12-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-11-17 | 2021-12-14 | 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 | 2021-11-18 | 2021-12-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-08-29 | 2019-09-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-29 | 2019-09-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-29 | 2019-09-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-29 | 2019-09-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-29 | 2019-09-27 | 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 | 2019-08-29 | 2019-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-29 | 2019-09-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-29 | 2019-09-27 | 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 | 2019-08-29 | 2019-09-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-08-29 | 2019-09-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-08-29 | 2019-09-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-08-29 | 2019-09-03 | N |
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