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Deficiency Records for Villa St Joseph
A list of the most recent deficiencies for Villa St Joseph. 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 St Joseph. 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 and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-09-18 | 2024-10-18 | 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 | 2024-09-18 | 2024-10-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-18 | 2024-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-17 | 2024-09-27 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-08-29 | 2024-09-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-29 | 2024-09-20 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-07-17 | 2024-08-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-17 | 2024-08-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-07-17 | 2024-08-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-17 | 2024-08-12 | 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 | 2024-07-17 | 2024-08-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-07-17 | 2024-08-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-17 | 2024-08-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-07-17 | 2024-08-12 | 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 | 2024-07-17 | 2024-08-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-07-17 | 2024-08-12 | 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 | 2024-07-17 | 2024-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-17 | 2024-08-12 | N |
| Keep all essential equipment working safely. | Health | 2024-07-17 | 2024-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2024-01-08 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-20 | 2023-04-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-20 | 2023-04-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-20 | 2023-04-13 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-20 | 2023-04-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-20 | 2023-04-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-20 | 2023-04-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-20 | 2023-04-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-20 | 2023-04-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-20 | 2023-04-13 | 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 | 2023-03-20 | 2023-04-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-20 | 2023-04-13 | 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 | 2023-03-20 | 2023-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-20 | 2023-04-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-14 | 2023-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-14 | 2023-03-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-14 | 2023-03-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-14 | 2023-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-14 | 2023-03-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-01 | 2022-05-24 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-08-11 | 2021-09-17 | 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 | 2021-08-11 | 2021-09-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-11 | 2021-09-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-11 | 2021-09-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-11 | 2021-09-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-11 | 2021-09-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-11 | 2021-09-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-11 | 2021-09-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-02 | 2021-08-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-02 | 2021-08-27 | 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 | 2021-08-02 | 2021-08-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-02 | 2021-08-27 | 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 | 2021-08-02 | 2021-08-27 | N |
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