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Deficiency Records for Villa at Borgess Place
A list of the most recent deficiencies for Villa at Borgess Place. 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 at Borgess Place. 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 | 2024-08-29 | 2024-10-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-29 | 2024-10-04 | N |
| 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 | 2024-08-29 | 2024-10-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-08-29 | 2024-10-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-29 | 2024-10-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-29 | 2024-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-29 | 2024-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-29 | 2024-10-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-29 | 2024-10-04 | 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 | 2024-08-29 | 2024-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-29 | 2024-10-04 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-08-29 | 2024-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-29 | 2024-10-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-29 | 2024-10-04 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-08-29 | 2024-10-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-09-04 | 2024-10-04 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-09-04 | 2024-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-04 | 2024-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-04 | 2024-10-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-09-04 | 2024-10-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-03 | 2024-02-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-06 | 2023-10-13 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-12 | 2023-08-09 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-07-12 | 2023-08-09 | 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 | 2023-07-12 | 2023-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-12 | 2023-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-12 | 2023-08-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-12 | 2023-08-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-12 | 2023-08-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-12 | 2023-08-09 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-13 | 2023-08-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-13 | 2023-08-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-13 | 2023-08-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-13 | 2023-08-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-24 | 2022-04-29 | 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 | 2022-03-24 | 2022-04-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-24 | 2022-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 2022-04-29 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-03-24 | 2022-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-24 | 2022-04-29 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-23 | 2022-04-11 | N |
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