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Deficiency Records for West Valley Post Acute
A list of the most recent deficiencies for West Valley Post Acute. 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 West Valley Post Acute. 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? |
|---|---|---|---|---|
| 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 | 2024-08-29 | 2024-09-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-07 | 2024-08-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-07 | 2024-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-07 | 2024-08-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | 2024-08-05 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-06-07 | 2024-06-24 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-20 | 2024-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-25 | 2024-02-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-25 | 2024-02-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-10 | 2024-02-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-10 | 2024-02-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-10 | 2024-02-06 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-01-10 | 2024-02-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-01 | 2023-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-06-24 | Y |
| 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 | 2023-03-17 | 2023-03-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-17 | 2023-03-29 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-17 | 2023-03-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-17 | 2023-03-29 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-02-22 | 2023-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-23 | 2022-09-29 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-08-02 | 2022-08-19 | Y |
| 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. | Health | 2022-07-24 | 2022-07-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-13 | 2022-06-15 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-28 | 2022-02-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-28 | 2022-02-25 | N |
| 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. | Health | 2022-01-28 | 2022-02-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-28 | 2022-02-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-28 | 2022-02-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-28 | 2022-02-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-28 | 2022-02-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-28 | 2022-02-25 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-01-28 | 2022-02-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-28 | 2022-02-25 | 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 | 2022-01-28 | 2022-02-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-28 | 2022-02-25 | 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 | 2022-01-28 | 2022-02-25 | 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 | 2022-01-28 | 2022-02-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-28 | 2022-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-28 | 2022-02-25 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-01-28 | 2022-02-25 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-01-28 | 2022-02-25 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-02-02 | 2022-02-20 | N |
| 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. | Fire Safety | 2022-02-02 | 2022-02-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-02-02 | 2022-02-20 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-02-02 | 2022-02-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-02 | 2022-02-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-02 | 2022-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-02 | 2022-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-02 | 2022-02-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-19 | 2019-10-18 | N |
| 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. | Health | 2019-09-19 | 2019-10-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-19 | 2019-10-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-19 | 2019-10-18 | 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 | 2019-09-19 | 2019-10-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-19 | 2019-10-18 | 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 | 2019-09-19 | 2019-10-18 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-09-19 | 2019-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-19 | 2019-10-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-19 | 2019-10-18 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-30 | 2019-10-18 | N |
| Establish methods for sharing information. | Fire Safety | 2019-09-30 | 2019-10-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-30 | 2019-10-18 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2019-09-30 | 2019-10-18 | 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 | 2019-09-30 | 2019-10-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-09-30 | 2019-10-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-30 | 2019-10-18 | N |
| 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. | Health | 2018-09-21 | 2018-10-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-09-21 | 2018-10-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-09-21 | 2018-10-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-21 | 2018-10-15 | 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 | 2018-09-21 | 2018-10-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-21 | 2018-10-15 | 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 | 2018-09-21 | 2018-10-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-09-21 | 2018-10-15 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2018-09-26 | 2018-10-15 | 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 | 2018-09-26 | 2018-10-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-09-26 | 2018-10-15 | 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 | 2018-09-26 | 2018-10-15 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-09-26 | 2018-10-15 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-19 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-09-21 | Not Fixed | N |
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