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Deficiency Records for Our Lady of The Valley

A list of the most recent deficiencies for Our Lady of The 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 Our Lady of The 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?
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-02-12 2024-03-28 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-02-12 2024-03-28 N
Provide enough food/fluids to maintain a resident's health. Health 2023-08-25 2023-10-24 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 2023-08-25 2023-10-24 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-25 2023-10-24 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-08-25 2023-10-24 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-25 2023-10-24 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2021-04-29 2021-06-15 N
Have properly located and lighted "Exit" signs. Fire Safety 2021-04-29 2021-06-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-04-29 2021-06-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-04-29 2021-06-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2021-04-29 2021-06-15 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2021-04-29 2021-06-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-04-29 2021-06-15 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2021-04-29 2021-06-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-04-29 2021-06-15 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-04-29 2021-06-15 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-04-15 2021-05-25 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 2021-04-15 2021-05-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-04-15 2021-05-25 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2021-04-15 2021-05-25 N
Provide and implement an infection prevention and control program. Health 2021-04-15 2021-05-25 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-04-15 2021-05-25 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2021-04-15 2021-05-25 N
Address patient/client population and determine types of services needed. Fire Safety 2021-04-15 2021-05-25 N
Address subsistence needs for staff and patients. Fire Safety 2021-04-15 2021-05-25 N
Establish policies and procedures for volunteers. Fire Safety 2021-04-15 2021-05-25 N
Conduct testing and exercise requirements. Fire Safety 2021-04-15 2021-05-25 N
Use approved construction type or materials. Fire Safety 2019-04-22 2019-06-20 N
Meet other general requirements that are deficient. Fire Safety 2019-04-22 2019-06-20 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-04-22 2019-06-20 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-04-22 2019-06-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-04-22 2019-06-20 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-04-08 2019-05-17 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 2019-04-08 2019-05-17 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 2019-04-08 2019-05-17 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-04-08 2019-05-17 N

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