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Deficiency Records for Ayer Valley Rehab and Nursing
A list of the most recent deficiencies for Ayer Valley Rehab and Nursing. 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 Ayer Valley Rehab and Nursing. 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? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-06-05 | 2024-06-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-05 | 2024-06-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-06-05 | 2024-06-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-03-05 | 2024-03-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-05 | 2024-03-25 | 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 | 2024-03-05 | 2024-03-25 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-03-05 | 2024-03-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-05 | 2024-03-25 | 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 | 2024-03-05 | 2024-03-25 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-03-05 | 2024-03-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-05 | 2024-03-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-05 | 2024-03-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-05 | 2024-03-25 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-03-05 | 2024-03-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-05 | 2024-03-25 | 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 | 2024-03-05 | 2024-03-25 | N |
| 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. | Health | 2024-03-05 | 2024-03-25 | 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 | 2024-03-05 | 2024-03-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-05 | 2024-03-25 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-05 | 2024-03-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-03-05 | 2024-03-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-03-05 | 2024-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-05 | 2024-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-12 | 2024-03-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-12 | 2024-03-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-05 | 2024-03-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-05 | 2024-03-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-12 | 2024-03-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-03-12 | 2024-03-22 | N |
| Develop a communication plan. | Fire Safety | 2024-03-12 | 2024-03-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-03-12 | 2024-03-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-12 | 2024-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-12 | 2024-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-12 | 2024-03-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-12-29 | 2024-02-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-29 | 2024-02-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-29 | 2024-02-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-29 | 2024-02-23 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-12-29 | 2024-02-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-29 | 2024-02-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-29 | 2024-02-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-29 | 2024-02-23 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-12-29 | 2024-02-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-29 | 2024-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-29 | 2024-02-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-29 | 2024-02-23 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-12-29 | 2024-02-23 | Y |
| 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 | 2023-09-27 | 2023-10-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-27 | 2023-09-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-27 | 2023-09-01 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-05 | 2023-08-04 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-07-05 | 2023-08-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-05 | 2023-08-04 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-04-11 | 2023-05-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-02 | 2023-02-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-02 | 2023-02-17 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-02 | 2023-02-17 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-06-16 | 2022-08-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-16 | 2022-08-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-16 | 2022-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-08-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-16 | 2022-08-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-22 | 2022-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-22 | 2022-07-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-07 | 2022-07-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-07 | 2022-07-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-16 | 2022-07-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-16 | 2022-07-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-16 | 2022-07-21 | N |
| 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. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-16 | 2022-07-21 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-06-16 | 2022-07-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-16 | 2022-07-21 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-16 | 2022-07-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-16 | 2022-05-02 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-16 | 2022-05-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-11 | 2022-03-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-11 | 2022-03-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-11 | 2022-03-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-11 | 2022-03-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-11 | 2022-03-04 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-16 | 2020-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-16 | 2019-11-30 | N |
| 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 | 2019-09-24 | 2019-11-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-24 | 2019-11-28 | 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 | 2019-09-24 | 2019-11-28 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-09-24 | 2019-11-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-24 | 2019-11-28 | 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 | 2019-09-24 | 2019-11-28 | N |
| 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. | Health | 2019-09-24 | 2019-11-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-24 | 2019-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-24 | 2019-11-28 | N |
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