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Deficiency Records for The Villa at West Branch
A list of the most recent deficiencies for The Villa at West Branch. 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 The Villa at West Branch. 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? |
---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-09 | 2024-06-13 | Y |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-05-09 | 2024-06-13 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-09 | 2024-06-13 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-09 | 2024-06-13 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-09 | 2024-06-13 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-09 | 2024-06-13 | 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 | 2024-05-09 | 2024-06-13 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-09 | 2024-06-13 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-09 | 2024-06-13 | N |
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-05-09 | 2024-06-13 | N |
Provide and implement an infection prevention and control program. | Health | 2024-05-09 | 2024-06-13 | N |
Implement a program that monitors antibiotic use. | Health | 2024-05-09 | 2024-06-13 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-09 | 2024-06-13 | Y |
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 | 2024-05-09 | 2024-06-13 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-09 | 2024-06-13 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-06 | 2023-08-08 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-06 | 2023-08-08 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-06 | 2023-08-08 | Y |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-07-06 | 2023-08-08 | Y |
Provide enough space and equipment to meet each resident's needs | Health | 2023-07-06 | 2023-08-08 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-07 | 2023-07-14 | 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 | 2023-05-24 | 2023-07-12 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-24 | 2023-07-12 | 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 | 2023-05-24 | 2023-07-12 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-24 | 2023-07-12 | N |
Post nurse staffing information every day. | Health | 2023-05-24 | 2023-07-12 | 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 | 2023-05-24 | 2023-07-12 | 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 | 2023-05-24 | 2023-07-12 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-24 | 2023-07-12 | N |
Provide and implement an infection prevention and control program. | Health | 2023-05-24 | 2023-07-12 | N |
Implement a program that monitors antibiotic use. | Health | 2023-05-24 | 2023-07-12 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-24 | 2023-07-12 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-24 | 2023-07-12 | Y |
Meet other general requirements. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Have exits that are accessible at all times. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Have power receptacles that are properly grounded. | Fire Safety | 2023-05-24 | 2023-07-12 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-08 | 2022-12-14 | Y |
Respond appropriately to all alleged violations. | Health | 2022-12-08 | 2022-12-14 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-13 | 2022-11-04 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-04 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-30 | 2022-04-15 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-30 | 2022-02-10 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-12-15 | N |
Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-12-15 | N |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-10-13 | 2021-11-04 | N |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-10-13 | 2021-11-04 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-10-13 | 2021-11-04 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-10-13 | 2021-11-04 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-13 | 2021-11-04 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-13 | 2021-11-04 | N |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-10-13 | 2021-11-04 | 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 | 2021-10-13 | 2021-11-04 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-13 | 2021-11-04 | N |
Implement a program that monitors antibiotic use. | Health | 2021-10-13 | 2021-11-04 | 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 | 2021-10-12 | 2021-11-04 | N |
Have power receptacles that are properly grounded. | Fire Safety | 2021-10-12 | 2021-11-04 | N |
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