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Deficiency Records for Sandstone Spring Valley
A list of the most recent deficiencies for Sandstone Spring Valley. 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 Sandstone Spring Valley. 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 safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-15 | 2024-03-07 | Y |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Establish policies and procedures including evacuation. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Establish emergency prep training and testing. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-22 | 2023-10-24 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-22 | 2023-10-24 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-22 | 2023-10-24 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-22 | 2023-10-24 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-24 | 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 | 2023-09-22 | 2023-10-24 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-22 | 2023-10-24 | 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 | 2023-09-22 | 2023-10-24 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-22 | 2023-10-24 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-22 | 2023-10-24 | 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 | 2023-09-22 | 2023-10-24 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-10-24 | N |
Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-10-24 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-22 | 2023-10-24 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-08 | 2023-03-01 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-08 | 2023-03-01 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-02 | 2022-09-21 | Y |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-08-02 | 2022-09-21 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-02 | 2022-09-21 | Y |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-02 | 2022-09-12 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-02 | 2022-09-12 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-02 | 2022-09-12 | 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 | 2022-08-02 | 2022-09-12 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-02 | 2022-09-12 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-02 | 2022-09-12 | 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 | 2022-08-02 | 2022-09-12 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-02 | 2022-09-12 | N |
Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-08-02 | 2022-09-12 | N |
Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-09-12 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-02 | 2022-09-12 | N |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-02 | 2022-09-12 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-02 | 2022-09-12 | Y |
Develop a communication plan. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
Establish emergency prep training and testing. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
Conduct testing and exercise requirements. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
Ensure a qualified health professional conducts resident assessments. | Health | 2022-08-02 | 2022-08-30 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-28 | 2022-02-24 | 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 | 2022-01-28 | 2022-02-24 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-28 | 2022-02-24 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-28 | 2022-02-24 | Y |
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 | 2022-01-28 | 2022-02-24 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Establish policies and procedures for volunteers. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Provide primary/alternate means for communication. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Provide family notifications of emergency plan. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Conduct testing and exercise requirements. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-14 | 2019-07-23 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-14 | 2019-07-23 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-14 | 2019-07-23 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-14 | 2019-07-23 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-14 | 2019-07-23 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-06-14 | 2019-07-23 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-14 | 2019-07-23 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-14 | 2019-07-23 | 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 | 2019-06-14 | 2019-07-23 | N |
Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-06-14 | 2019-07-23 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-14 | 2019-07-09 | N |
Ensure each resident receives an accurate assessment. | Health | 2019-06-14 | 2019-07-08 | 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 | 2019-06-14 | 2019-07-08 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-14 | 2019-07-04 | 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 | 2019-06-14 | 2019-07-01 | 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 | 2019-06-14 | 2019-06-30 | N |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-06-14 | 2019-06-25 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-14 | 2019-06-18 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-14 | 2019-06-17 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-06-14 | 2019-06-16 | N |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-06-14 | 2019-06-15 | N |
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