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Deficiency Records for Villa St Vincent
A list of the most recent deficiencies for Villa St Vincent. 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 St Vincent. 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? |
|---|---|---|---|---|
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-07-31 | 2024-09-02 | 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 | 2024-07-31 | 2024-09-02 | 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 | 2024-07-31 | 2024-09-02 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-07-31 | 2024-09-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-31 | 2024-09-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-31 | 2024-09-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-07-31 | 2024-09-02 | Y |
| Install proper backup exit lighting. | Fire Safety | 2024-07-30 | 2024-09-02 | 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 | 2024-07-30 | 2024-09-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-30 | 2024-09-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-09 | 2024-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-31 | 2024-07-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-02 | 2024-05-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-29 | 2023-08-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-29 | 2023-08-14 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-29 | 2023-08-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-29 | 2023-08-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-08-14 | 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 | 2023-06-29 | 2023-08-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-29 | 2023-08-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-29 | 2023-08-14 | N |
| Post nurse staffing information every day. | Health | 2023-06-29 | 2023-08-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-27 | 2023-08-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-27 | 2023-08-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-27 | 2023-08-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-27 | 2023-08-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-27 | 2023-08-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-27 | 2023-08-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-27 | 2023-08-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-29 | 2023-08-04 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-21 | 2023-01-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-21 | 2023-01-31 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-20 | 2022-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-21 | 2022-08-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-07-21 | 2022-08-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-20 | 2022-08-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-20 | 2022-08-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-20 | 2022-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-20 | 2022-08-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-25 | 2022-06-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-25 | 2022-06-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-25 | 2022-06-22 | Y |
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