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Deficiency Records for Villa Siena
A list of the most recent deficiencies for Villa Siena. 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 Siena. 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-23 | 2024-05-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-22 | 2024-05-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-22 | 2024-05-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-22 | 2024-05-09 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-04-22 | 2024-05-09 | 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 | 2024-04-22 | 2024-05-09 | 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 | 2024-04-22 | 2024-05-09 | 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 | 2024-04-22 | 2024-05-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-22 | 2024-05-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-04-22 | 2024-05-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-22 | 2024-05-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-22 | 2024-05-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-04-22 | 2024-05-09 | Y |
| 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 | 2023-08-24 | 2023-08-25 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-12-14 | 2023-01-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-14 | 2023-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2023-01-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-14 | 2023-01-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-14 | 2023-01-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-14 | 2023-01-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-09 | 2023-01-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2023-01-08 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-12-09 | 2023-01-08 | 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 | 2022-12-09 | 2023-01-08 | N |
| Post nurse staffing information every day. | Health | 2022-12-09 | 2023-01-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-09 | 2023-01-08 | 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 | 2022-12-09 | 2023-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-09 | 2023-01-08 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2022-12-09 | 2023-01-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-09 | 2023-01-08 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-25 | 2020-04-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-06 | 2020-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-06 | 2020-02-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-06 | 2020-02-28 | 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 | 2020-02-06 | 2020-02-28 | 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 | 2020-02-06 | 2020-02-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-06 | 2020-02-28 | N |
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