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Deficiency Records for Mar Vista Country Villa Healthcare and Wellness

A list of the most recent deficiencies for Mar Vista Country Villa Healthcare and Wellness. 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 Mar Vista Country Villa Healthcare and Wellness. 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 that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2024-08-12 2024-09-10 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-07-29 2024-08-27 Y
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2024-07-29 2024-08-27 Y
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Health 2024-07-29 2024-08-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-06-05 2024-07-05 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-03-13 2024-04-04 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-15 2024-03-31 Y
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Health 2024-02-06 2024-02-26 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-02 2024-02-26 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-21 2023-12-19 Y
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2023-11-10 2023-12-10 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 2023-11-10 2023-12-10 Y
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2023-11-10 2023-12-10 Y
Implement emergency and standby power systems. Fire Safety 2023-10-10 2023-11-09 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-10-10 2023-11-09 N
Have exits that are accessible at all times. Fire Safety 2023-10-10 2023-11-09 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-10-10 2023-11-09 N
Have an enclosure around a vertical opening shaft. Fire Safety 2023-10-10 2023-11-09 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 2023-10-10 2023-11-09 N
Construct fire resistant interior walls. Fire Safety 2023-10-10 2023-11-09 N
Install an approved automatic sprinkler system. Fire Safety 2023-10-10 2023-11-09 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-10-10 2023-11-09 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-10-10 2023-11-09 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2023-10-10 2023-11-09 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-10-10 2023-11-09 N
Install properly constructed windows in hallway walls or doors. Fire Safety 2023-10-10 2023-11-09 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-10-10 2023-11-09 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-10-10 2023-11-09 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-10-10 2023-11-09 N
Have proper medical gas storage and administration areas. Fire Safety 2023-10-10 2023-11-09 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-10-06 2023-11-05 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2023-10-06 2023-11-05 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-10-06 2023-11-05 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-10-06 2023-11-05 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2023-10-06 2023-11-05 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 2023-10-06 2023-11-05 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-10-06 2023-11-05 N
Provide and implement an infection prevention and control program. Health 2023-10-06 2023-11-05 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-09-26 2023-10-25 Y
Ensure that residents are free from significant medication errors. Health 2023-09-26 2023-10-25 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-07-24 2023-08-04 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-06-22 2023-07-22 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-06-22 2023-07-22 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-10-05 2022-10-27 N
Reasonably accommodate the needs and preferences of each resident. Health 2022-10-05 2022-10-27 N
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 2022-10-05 2022-10-27 N
Keep residents' personal and medical records private and confidential. Health 2022-10-05 2022-10-27 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-10-05 2022-10-27 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-10-05 2022-10-27 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 2022-10-05 2022-10-27 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-10-05 2022-10-27 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 2022-10-05 2022-10-27 N
Post nurse staffing information every day. Health 2022-10-05 2022-10-27 N
Ensure that residents are free from significant medication errors. Health 2022-10-05 2022-10-27 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 2022-10-05 2022-10-27 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-10-05 2022-10-27 N
Provide and implement an infection prevention and control program. Health 2022-10-05 2022-10-27 N
Implement emergency and standby power systems. Fire Safety 2022-10-05 2022-10-27 N
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Fire Safety 2022-10-05 2022-10-27 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 2022-10-05 2022-10-27 N
Have exits that are accessible at all times. Fire Safety 2022-10-05 2022-10-27 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-10-05 2022-10-27 N
Construct fire resistant interior walls. Fire Safety 2022-10-05 2022-10-27 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-10-05 2022-10-27 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-10-05 2022-10-27 N
Provide a written emergency evacuation plan. Fire Safety 2022-10-05 2022-10-27 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-10-05 2022-10-27 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-07-06 2022-08-11 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-07-06 2022-08-11 Y
Provide and implement an infection prevention and control program. Health 2022-07-06 2022-08-11 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-05-31 2022-06-10 Y
Provide and implement an infection prevention and control program. Health 2022-05-25 2022-06-07 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 2022-05-20 2022-06-03 Y
Provide and implement an infection prevention and control program. Health 2022-05-19 2022-05-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-05-10 2022-05-27 Y
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2022-03-04 2022-03-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-03-06 2022-03-15 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-03-05 2022-03-12 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 2021-12-31 2022-01-12 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-12-24 2022-01-03 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-10-13 2021-11-04 Y
Provide and implement an infection prevention and control program. Health 2021-10-04 2021-10-15 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 2020-01-15 2020-02-11 N
Install properly constructed windows in hallway walls or doors. Fire Safety 2020-01-15 2020-02-11 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-01-15 2020-02-11 N
Have proper medical gas storage and administration areas. Fire Safety 2020-01-15 2020-02-11 N
Reasonably accommodate the needs and preferences of each resident. Health 2020-01-09 2020-02-04 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2020-01-09 2020-02-04 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-01-09 2020-02-04 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2020-01-09 2020-02-04 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2020-01-09 2020-02-04 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-01-09 2020-02-04 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 2020-01-09 2020-02-04 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 2020-01-09 2020-02-04 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2020-01-09 2020-02-04 N
Ensure medication error rates are not 5 percent or greater. Health 2020-01-09 2020-02-04 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 2020-01-09 2020-02-04 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2020-01-09 2020-02-04 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-01-09 2020-02-04 N
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Health 2020-01-09 2020-02-04 N
Provide and implement an infection prevention and control program. Health 2020-01-09 2020-02-04 N
Keep all essential equipment working safely. Health 2020-01-09 2020-02-04 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 2022-02-03 Not Fixed N
Provide and implement an infection prevention and control program. Health 2022-02-03 Not Fixed N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2022-02-03 Not Fixed N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-02-03 Not Fixed N

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