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Deficiency Records for Villa Maria
A list of the most recent deficiencies for Villa Maria. 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 Maria. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-08 | 2023-03-22 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-08 | 2023-03-22 | 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 | 2023-02-08 | 2023-03-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-08 | 2023-03-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-08 | 2023-03-22 | 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 | 2023-02-08 | 2023-03-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-08 | 2023-03-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-02-15 | 2023-03-10 | 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 | 2023-02-15 | 2023-03-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-15 | 2023-03-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-11 | 2021-07-29 | 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 | 2021-06-11 | 2021-07-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-11 | 2021-07-29 | 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 | 2021-06-11 | 2021-07-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-11 | 2021-07-29 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-04-20 | 2021-05-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-20 | 2021-05-26 | 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 | 2021-04-20 | 2021-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-20 | 2021-05-26 | 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 | 2021-04-20 | 2021-05-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-20 | 2021-05-26 | 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 | 2021-04-20 | 2021-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-20 | 2021-05-26 | N |
| Dispose of garbage and refuse properly. | Health | 2021-04-20 | 2021-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-20 | 2021-05-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-30 | 2019-11-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-30 | 2019-11-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-30 | 2019-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-30 | 2019-11-19 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-08-30 | 2019-11-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-30 | 2019-10-15 | 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 | 2019-08-30 | 2019-10-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-30 | 2019-10-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-30 | 2019-10-15 | 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 | 2019-06-25 | 2019-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-25 | 2019-07-20 | 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 | 2019-06-25 | 2019-07-20 | 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 | 2019-06-25 | 2019-07-20 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2019-06-25 | 2019-07-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-06-25 | 2019-07-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-25 | 2019-07-20 | N |
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