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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?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-04-16 2024-10-15 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 2024-04-16 2024-10-15 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 2024-10-15 N
Respond appropriately to all alleged violations. Health 2024-04-16 2024-09-26 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-04-16 2024-09-26 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 2024-09-26 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 2024-09-26 N
Have power receptacles that are properly grounded. Fire Safety 2024-04-12 2024-09-26 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 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
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
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
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
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
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
Inspect, test, and maintain automatic sprinkler systems. 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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