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Deficiency Records for St Joseph's Hillside Villa
A list of the most recent deficiencies for St Joseph's Hillside Villa. 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 St Joseph's Hillside Villa. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-07 | 2024-03-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-07 | 2024-03-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-07 | 2024-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-05 | 2024-03-29 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2024-03-05 | 2024-03-29 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-24 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-24 | 2023-05-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-15 | 2023-04-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-15 | 2023-04-07 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-07 | 2023-03-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-07 | 2023-03-15 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-02-07 | 2023-03-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-02-07 | 2023-03-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-07 | 2023-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-07 | 2023-03-15 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-02-07 | 2023-03-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-07 | 2023-03-07 | 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 | 2023-02-07 | 2023-03-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-07 | 2023-03-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-07 | 2023-03-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-07 | 2023-03-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-07 | 2023-03-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-07 | 2023-03-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-02-07 | 2023-03-01 | 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 | 2023-02-07 | 2023-03-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-07 | 2023-03-01 | 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 | 2023-02-07 | 2023-03-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-02-07 | 2023-03-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-07 | 2023-03-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-02-07 | 2023-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-07 | 2021-10-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-07 | 2021-10-26 | N |
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