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Deficiency Records for Village Creek Nursing and Rehabilitation
A list of the most recent deficiencies for Village Creek Nursing and Rehabilitation. 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 Village Creek Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-07-11 | 2024-08-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-07-11 | 2024-08-23 | 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 | 2024-07-11 | 2024-08-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-11 | 2024-08-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-11 | 2024-08-16 | 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 | 2024-07-11 | 2024-07-15 | N |
| 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 | 2024-07-11 | 2024-07-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-07-11 | 2024-07-12 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2024-07-11 | 2024-07-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-11 | 2024-07-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-25 | 2024-05-26 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-14 | 2023-07-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-15 | 2023-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-15 | 2023-06-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-15 | 2023-06-16 | 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 | 2023-06-15 | 2023-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-15 | 2023-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-15 | 2023-06-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-14 | 2023-06-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-14 | 2023-06-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-20 | 2023-04-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-09 | 2022-08-11 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-06-29 | 2022-07-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-29 | 2022-07-25 | Y |
| Develop a communication plan. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-11 | 2022-06-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-11 | 2022-06-17 | 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 | 2022-05-12 | 2022-06-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-12 | 2022-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-12 | 2022-06-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-12 | 2022-06-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-06-12 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-11 | 2022-05-12 | N |
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