Villa Maria Post Acute and Rehabilitation

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Rights Deficiencies

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.

Resident Rights Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Nursing and Physician Services Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Install resident room doors of proper design and width.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

Based on observations, interviews, facility documentation and policy, the facility failed to ensure that safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances for two of three medication carts sampled. The deficient practice could result in inventory loss and potential diversion.Â

 Based on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure insulin was administered according to provider instruction for one resident (#5). This deficient practice could result in side effects leading to negative resident outcomes. The sample size was 5. The universe was 56. Â

Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure the clinical record for one resident (# 9), contained an accurate representation of the actual experiences of a resident with an allegation of resident to resident abuse, and was accurate, complete and readily available for one resident (#50). The deficient practice could result in records that do not accurately and completely reflect the care and services provided to residents.

Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure the clinical record for one resident (# 9) contained an accurate representation of the actual experiences of a resident with an allegation of resident to resident abuse.Â

Based on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure insulin was administered according to provider instruction for one resident (#5).The sample size was 5. The census was 56.Â

Based on review of records, staff interviews and review of policy and procedures, the facility failed to ensure that timely care and services, including physician notification and a physician order for oxygen, were provided upon a change of condition for one resident (#50).Â

Based on observations, interviews, facility documentation and policy, the facility failed to ensure that safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances for two of three medication carts sampled. Â

Based on interviews, clinical record review, personnel record review, facility documentation and policy; the facility failed to ensure one resident (#9) with mental health diagnosis and needs was referred to the appropriate state-designated mental health authority for review. This deficient practice can result in residents medically related social and emotional needs not being met. The sample size was 8. The census was 56.     Â

Based on the interview, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure PASSAR screening and referral were accurate and completed for 6residents (#3, #5, #9, #13, #21, and #55). This deficient practice can result in residents medically related social and emotional needs not being met.  The sample size was 8. The census was 56.Â

Number of residents sampled: 15Number of residents cited: 2Universe: 56Based on review of records, staff interviews and review of policy and procedures, the facility failed to ensure that timely care and services, including physician notification and a physician order for oxygen, were provided upon a change of condition for one resident (#50). The deficient practice could lead to a medical decline and/or physical harm of a resident.

Violation cited

Based on observation and staff interviews, the facility failed to ensure that a remote stop or kill switch for the generator was installed. This could affect the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the exterior of the generator could cause a fire or harm the residents and staff.