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Deficiency Records for Pleasant Valley Manor, Inc
A list of the most recent deficiencies for Pleasant Valley Manor, Inc. 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 Pleasant Valley Manor, Inc. 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 | 2024-05-29 | 2024-07-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-29 | 2024-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-29 | 2024-07-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-15 | 2023-12-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-15 | 2023-12-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-15 | 2023-12-06 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-15 | 2023-11-01 | 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 | 2023-09-15 | 2023-11-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-15 | 2023-11-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-15 | 2023-11-01 | 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 | 2023-09-15 | 2023-11-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-09-15 | 2023-11-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-15 | 2023-11-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-09-15 | 2023-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-15 | 2023-11-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-15 | 2023-11-01 | N |
| Have policies on smoking. | Health | 2023-09-15 | 2023-11-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-15 | 2023-11-01 | 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 | 2023-09-15 | 2023-11-01 | Y |
| Meet other general requirements. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-19 | 2023-10-25 | 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 | 2023-09-19 | 2023-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-19 | 2023-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-21 | 2023-01-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-21 | 2023-01-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-21 | 2022-12-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-21 | 2022-12-09 | 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 | 2022-10-21 | 2022-12-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-21 | 2022-12-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-21 | 2022-12-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-21 | 2022-12-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-21 | 2022-12-09 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-21 | 2022-12-09 | 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 | 2022-10-21 | 2022-12-09 | 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 | 2022-10-21 | 2022-12-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-21 | 2022-12-09 | N |
| Provide or obtain dental services for each resident. | Health | 2022-10-21 | 2022-12-09 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-10-21 | 2022-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-21 | 2022-12-09 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-21 | 2022-12-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-10-21 | 2022-12-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-12-09 | N |
| Report COVID19 data to residents and families. | Health | 2022-10-21 | 2022-12-09 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-10-21 | 2022-12-09 | N |
| Keep all essential equipment working safely. | Health | 2022-10-21 | 2022-12-09 | 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 | 2022-10-21 | 2022-12-09 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-21 | 2022-12-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-12-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-25 | 2022-12-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-12-09 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-12 | 2022-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-01 | 2022-03-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-01 | 2022-03-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-19 | 2022-03-07 | 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 | 2021-11-19 | 2022-02-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-11-19 | 2022-02-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-19 | 2022-02-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-19 | 2022-02-01 | 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 | 2021-11-19 | 2022-02-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-19 | 2022-02-01 | 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 | 2021-11-19 | 2022-02-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-19 | 2022-02-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-19 | 2022-02-01 | 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 | 2021-11-19 | 2022-02-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-11-19 | 2022-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-19 | 2022-02-01 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-11-19 | 2022-02-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-11-19 | 2022-02-01 | 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 | 2021-11-29 | 2022-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-29 | 2022-01-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-29 | 2022-01-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-29 | 2022-01-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-29 | 2022-01-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-25 | Not Fixed | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-25 | Not Fixed | Y |
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