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Deficiency Records for Villa Rosa Nursing and Rehabilitation, LLC
A list of the most recent deficiencies for Villa Rosa Nursing and Rehabilitation, LLC. 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 Rosa Nursing and Rehabilitation, LLC. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-03 | 2024-10-28 | 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 | 2024-06-03 | 2024-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-03 | 2024-10-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-03 | 2024-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-03 | 2024-10-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-06-03 | 2024-10-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-03 | 2024-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-03 | 2024-10-28 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-06-03 | 2024-09-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-03 | 2024-09-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-06-03 | 2024-09-04 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-06-03 | 2024-07-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-06-03 | 2024-07-22 | 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 | 2024-06-03 | 2024-07-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-06-03 | 2024-07-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-03 | 2024-07-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-03 | 2024-07-22 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-06-03 | 2024-07-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-03 | 2024-07-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-06-03 | 2024-07-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-31 | 2024-07-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-31 | 2024-07-01 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-05-31 | 2024-07-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-31 | 2024-07-01 | 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 | 2024-05-31 | 2024-07-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-31 | 2024-07-01 | 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 | 2024-05-31 | 2024-07-01 | N |
| Provide activities to meet all resident's needs. | Health | 2024-05-31 | 2024-07-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-31 | 2024-07-01 | 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 | 2024-05-31 | 2024-07-01 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-05-31 | 2024-07-01 | 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 | 2024-05-31 | 2024-07-01 | N |
| Provide or obtain dental services for each resident. | Health | 2024-05-31 | 2024-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-31 | 2024-07-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-31 | 2024-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-31 | 2024-07-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-05-31 | 2024-07-01 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-05-31 | 2024-07-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-05-31 | 2024-07-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-05-31 | 2024-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-31 | 2024-07-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-31 | 2024-07-01 | Y |
| 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 | 2024-05-31 | 2024-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-31 | 2024-07-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-31 | 2024-07-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-31 | 2024-07-01 | Y |
| 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 | 2019-05-13 | 2019-07-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-05-13 | 2019-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-13 | 2019-07-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-13 | 2019-07-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-22 | 2018-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-22 | 2018-01-22 | 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 | 2017-12-22 | 2018-01-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-12-22 | 2018-01-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2017-12-22 | 2018-01-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2017-12-22 | 2018-01-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2017-12-22 | 2018-01-22 | 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 | 2017-12-22 | 2018-01-22 | 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 | 2017-12-22 | 2018-01-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-22 | 2018-01-22 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2017-12-22 | 2018-01-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2017-12-22 | 2018-01-22 | N |
| Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. | Health | 2017-12-22 | 2018-01-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-22 | 2018-01-22 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2017-12-22 | 2018-01-22 | N |
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