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Deficiency Records for Belleview Valley Nursing Home
A list of the most recent deficiencies for Belleview Valley Nursing Home. 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 Belleview Valley Nursing Home. 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 | 2024-04-16 | 2024-07-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-16 | 2024-07-10 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-04-16 | 2024-07-10 | N |
| 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. | Health | 2024-04-16 | 2024-07-10 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-04-16 | 2024-07-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-04-16 | 2024-07-10 | 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 | 2024-04-12 | 2024-06-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-12 | 2024-06-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-12 | 2024-06-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-16 | 2024-05-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-16 | 2024-05-31 | 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 | 2024-04-16 | 2024-05-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-04-16 | 2024-05-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-16 | 2024-05-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-16 | 2024-05-31 | N |
| Respond appropriately to all alleged violations. | Health | 2024-04-16 | 2024-05-31 | 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 | 2024-04-16 | 2024-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-16 | 2024-05-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-16 | 2024-05-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-16 | 2024-05-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-16 | 2024-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-16 | 2024-05-31 | 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 | 2024-04-16 | 2024-05-31 | 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 | 2024-04-16 | 2024-05-31 | 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 | 2024-04-16 | 2024-05-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-16 | 2024-05-31 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-04-16 | 2024-05-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-16 | 2024-05-31 | 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 | 2024-04-16 | 2024-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-16 | 2024-05-31 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-04-16 | 2024-05-31 | N |
| Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2024-04-16 | 2024-05-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-04-16 | 2024-05-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-04-16 | 2024-05-31 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-04-16 | 2024-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-16 | 2024-05-31 | N |
| 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. | Health | 2024-04-16 | 2024-05-31 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-04-16 | 2024-05-31 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-04-16 | 2024-05-31 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-04-16 | 2024-05-31 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-04-16 | 2024-05-31 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-04-16 | 2024-05-31 | 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 | 2024-04-12 | 2024-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-12 | 2024-05-31 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-04-12 | 2024-05-31 | 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 | 2023-11-09 | 2023-12-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-09 | 2023-12-20 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-10-19 | 2022-11-30 | 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 | 2022-10-19 | 2022-11-30 | 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 | 2022-10-19 | 2022-11-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-19 | 2022-11-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-19 | 2022-11-30 | 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 | 2022-10-19 | 2022-11-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-10-19 | 2022-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-19 | 2022-11-30 | 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 | 2022-10-19 | 2022-11-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-19 | 2022-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-19 | 2022-11-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-19 | 2022-11-30 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-10-19 | 2022-11-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-19 | 2022-11-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-19 | 2022-11-30 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-10-19 | 2022-11-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-10-19 | 2022-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-19 | 2022-11-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-19 | 2022-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-19 | 2022-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-19 | 2022-11-30 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-03-31 | 2022-04-15 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-13 | 2020-04-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-03-13 | 2020-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-13 | 2020-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-13 | 2020-03-25 | 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 | 2020-03-13 | 2020-03-25 | N |
| 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. | Health | 2020-03-13 | 2020-03-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-13 | 2020-03-14 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-03-13 | 2020-03-14 | 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 | 2022-10-19 | Not Fixed | N |
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