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Deficiency Records for Spring Valley Post Acute LLC
A list of the most recent deficiencies for Spring Valley Post Acute LLC. 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 Spring Valley Post Acute LLC. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-12 | 2024-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-09 | 2023-10-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-26 | 2023-10-16 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-23 | 2023-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-31 | 2023-09-11 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-04 | 2022-04-05 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-02-04 | 2022-04-05 | 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 | 2022-02-04 | 2022-04-05 | 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 | 2022-02-04 | 2022-04-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-04 | 2022-04-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-04 | 2022-04-05 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-04 | 2022-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-04 | 2022-04-05 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-04 | 2022-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-04-05 | N |
| Keep all essential equipment working safely. | Health | 2022-02-04 | 2022-04-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Use approved construction type or materials. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-24 | 2022-03-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-03-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-13 | 2021-12-27 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-04 | 2019-07-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-04-15 | 2019-05-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-15 | 2019-05-22 | 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 | 2019-04-15 | 2019-05-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-15 | 2019-05-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-15 | 2019-05-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-15 | 2019-05-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-15 | 2019-05-22 | 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 | 2019-04-15 | 2019-05-22 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-04-15 | 2019-05-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-04-15 | 2019-05-22 | 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 | 2019-04-15 | 2019-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-15 | 2019-05-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-15 | 2019-05-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Use approved construction type or materials. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-05-16 | 2018-06-05 | 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 | 2018-05-16 | 2018-06-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-16 | 2018-06-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-23 | 2018-05-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-03-23 | 2018-05-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-23 | 2018-05-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-03-23 | 2018-05-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-23 | 2018-05-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-23 | 2018-05-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-23 | 2018-05-02 | 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 | 2018-03-23 | 2018-05-02 | N |
| 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 necessary and PRN use is limited. | Health | 2018-03-23 | 2018-05-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-23 | 2018-05-02 | 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 | 2018-03-23 | 2018-05-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-23 | 2018-05-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-23 | 2018-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-23 | 2018-05-02 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2018-03-23 | 2018-05-02 | N |
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