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Villa Clara Post Acute

Inspection Results


Nursing Homes Illinois Decatur Villa Clara Post Acute

Villa Clara Post Acute has been cited for a total of 139 deficiencies in our most recent deficiency data, which typically covers 3 health and fire safety surveys.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Villa Clara Post Acute.

There are 711 nursing homes in Illinois with a total of 34,918 deficiencies resulting in an average of 49.11 deficiencies per nursing home.



The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies


Deficiency Cited, Scope, and Date of Correction
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
Corrected:
11-13-2020

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-13-2020

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
Corrected:
11-13-2020

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
F
Corrected:
11-13-2020

Report COVID19 data to residents and families.
Category:
Infection Control Deficiencies
Scope:
F
Corrected:
11-13-2020

Perform COVID19 testing on residents and staff.
Category:
Infection Control Deficiencies
Scope:
D
Corrected:
11-13-2020

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
Corrected:
06-16-2020

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
10-01-2020

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
10-01-2020

Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
10-01-2020

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
10-01-2020

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
10-01-2020

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
09-02-2020

Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
Corrected:
09-02-2020

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
Corrected:
09-02-2020

Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
Corrected:
09-02-2020

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
09-02-2020

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
09-02-2020

Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
09-02-2020

Provide safe, appropriate pain management for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
09-02-2020

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
09-02-2020

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
09-02-2020

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
E
Corrected:
12-06-2019

Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
12-06-2019

Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
12-06-2019

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.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
Corrected:
12-06-2019

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
Corrected:
12-06-2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-06-2019

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-06-2019

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.
Category:
Resident Rights Deficiencies
Scope:
E
Corrected:
09-26-2019

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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
Corrected:
07-08-2019

Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
Corrected:
07-08-2019

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.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
07-03-2019

Provide appropriate treatment and care according to orders, resident?s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
07-03-2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
07-03-2019

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
07-03-2019

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 ne
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
07-03-2019

Ensure that residents are free from significant medication errors.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
07-03-2019

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
Corrected:
07-03-2019

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
07-03-2019

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
Corrected:
07-03-2019

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
06-06-2019

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
06-06-2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
06-16-2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
05-24-2019

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
11-08-2018

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.
Category:
Resident Rights Deficiencies
Scope:
E
Corrected:
11-08-2018

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
Corrected:
11-08-2018

Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
Corrected:
11-08-2018

Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
Corrected:
11-08-2018

Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
11-08-2018

Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
11-08-2018

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
Corrected:
11-08-2018

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
Corrected:
11-08-2018

Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
E
Corrected:
11-08-2018

Provide appropriate treatment and care according to orders, resident?s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

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
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

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.
Category:
Nursing and Physician Services Deficiencies
Scope:
F
Corrected:
11-08-2018

Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
Corrected:
11-08-2018

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
11-08-2018

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
Corrected:
11-08-2018

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 ne
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
11-08-2018

Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
11-08-2018

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.
Category:
Pharmacy Service Deficiencies
Scope:
E
Corrected:
11-08-2018

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
Corrected:
11-08-2018

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
F
Corrected:
11-08-2018

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
F
Corrected:
11-08-2018

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Category:
Environmental Deficiencies
Scope:
D
Corrected:
11-08-2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
Corrected:
02-13-2019

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Category:
Nutrition and Dietary Deficiencies
Scope:
C
Corrected:
10-04-2018

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.
Category:
Nutrition and Dietary Deficiencies
Scope:
B
Corrected:
10-18-2018

Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of schedul
Category:
Nutrition and Dietary Deficiencies
Scope:
E
Corrected:
10-04-2018

Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
09-19-2018

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
Corrected:
09-18-2018

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
09-18-2018

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
E
Corrected:
09-18-2018

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
09-19-2018

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
09-19-2018

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
E
Corrected:
09-18-2018

Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
08-27-2018

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
09-19-2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
09-19-2018

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
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
09-19-2018

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 ne
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
09-19-2018

Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
09-19-2018

Employ staff that are licensed, certified, or registered in accordance with state laws.
Category:
Administration Deficiencies
Scope:
E
Corrected:
09-19-2018

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
Corrected:
09-19-2018

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Category:
Environmental Deficiencies
Scope:
D
Corrected:
09-19-2018

Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
08-28-2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
07-27-2018

Honor the resident's right to organize and participate in resident/family groups in the facility.
Category:
Resident Rights Deficiencies
Scope:
C
Corrected:
05-07-2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
05-04-2018

Provide routine and 24-hour emergency dental care for each resident.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
04-27-2018

Keep residents' personal and medical records private and confidential.
Category:
Resident Rights Deficiencies
Scope:
D
Corrected:
02-21-2018

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.
Category:
Resident Rights Deficiencies
Scope:
E
Corrected:
02-21-2018

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
02-21-2018

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
Corrected:
02-21-2018

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
02-21-2018

Provide care by qualified persons according to each resident's written plan of care.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
Corrected:
03-02-2018

Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
02-21-2018

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
02-21-2018

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.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
02-21-2018

Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
Corrected:
02-21-2018

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
02-21-2018

Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
Corrected:
03-02-2018

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.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
Corrected:
02-21-2018

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
Corrected:
02-21-2018

Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
Corrected:
02-21-2018

Address patient/client population and determine types of services needed.
Category:
Emergency Preparedness Deficiencies
Scope:
F
Corrected:
12-06-2019

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.
Category:
Egress Deficiencies
Scope:
E
Corrected:
12-06-2019

Have exits that are accessible at all times.
Category:
Egress Deficiencies
Scope:
E
Corrected:
12-04-2019

Provide properly protected cooking facilities.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
12-06-2019

Have approved installation, maintenance and testing program for fire alarm systems.
Category:
Smoke Deficiencies
Scope:
F
Corrected:
12-06-2019

Inspect, test, and maintain automatic sprinkler systems.
Category:
Smoke Deficiencies
Scope:
F
Corrected:
12-05-2019

Install corridor and hallway doors that block smoke.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
12-05-2019

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
12-05-2019

Install smoke barrier doors that can resist smoke for at least 20 minutes.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
12-06-2019

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
11-14-2018

Install corridor and hallway doors that block smoke.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
11-05-2018

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
11-05-2018

Install smoke barrier doors that can resist smoke for at least 20 minutes.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
11-05-2018

Have simulated fire drills held at unexpected times.
Category:
Miscellaneous Deficiencies
Scope:
F
Corrected:
11-05-2018

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Category:
Miscellaneous Deficiencies
Scope:
F
Corrected:
11-05-2018

Have generator or other power source capable of supplying service within 10 seconds.
Category:
Gas, Vacuum, and Electrical Systems Deficiencies
Scope:
F
Corrected:
11-05-2018

Ensure proper usage of power strips and extension cords.
Category:
Gas, Vacuum, and Electrical Systems Deficiencies
Scope:
E
Corrected:
11-05-2018

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Category:
Gas, Vacuum, and Electrical Systems Deficiencies
Scope:
F
Corrected:
11-05-2018

Inspect, test, and maintain automatic sprinkler systems.
Category:
Smoke Deficiencies
Scope:
F
Corrected:
01-08-2018

Install smoke barrier doors that can resist smoke for at least 20 minutes.
Category:
Smoke Deficiencies
Scope:
E
Corrected:
01-08-2018

Have simulated fire drills held at unexpected times.
Category:
Miscellaneous Deficiencies
Scope:
F
Corrected:
01-08-2018

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Category:
Miscellaneous Deficiencies
Scope:
E
Corrected:
01-08-2018

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Category:
Gas, Vacuum, and Electrical Systems Deficiencies
Scope:
F
Corrected:
01-08-2018

Have generator or other power source capable of supplying service within 10 seconds.
Category:
Gas, Vacuum, and Electrical Systems Deficiencies
Scope:
F
Corrected:
01-08-2018

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Category:
Gas, Vacuum, and Electrical Systems Deficiencies
Scope:
E
Corrected:
01-08-2018



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Villa Clara Post Acute


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