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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
Provide and implement an infection prevention and control program. Health 2021-10-13 2021-12-15 N
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 Y
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
Plan the resident's discharge to meet the resident's goals and needs. Health 2021-10-13 2021-11-04 Y
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 Y
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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