ST DOMINIC VILLA

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 23, 2026

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 23, 2026

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 23, 2026

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 23, 2026

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 1, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 19, 2023

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 19, 2023

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 19, 2023

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected March 1, 2024

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 1, 2024

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 1, 2024

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2024

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 19, 2023

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 19, 2023