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Deficiency Records for Aurora Valley Care
A list of the most recent deficiencies for Aurora Valley Care. 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 Aurora Valley Care. 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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-09-12 | 2024-10-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-12 | 2024-10-09 | Y |
| 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 | 2024-09-12 | 2024-10-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-21 | 2024-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-27 | 2024-07-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-06-27 | 2024-07-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-06-27 | 2024-07-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-06-27 | 2024-07-24 | 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 | 2024-06-27 | 2024-07-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-06-27 | 2024-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-27 | 2024-07-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-27 | 2024-07-24 | N |
| Provide activities to meet all resident's needs. | Health | 2024-06-27 | 2024-07-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-27 | 2024-07-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-06-27 | 2024-07-24 | 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 | 2024-06-27 | 2024-07-24 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-06-27 | 2024-07-24 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-06-27 | 2024-07-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-27 | 2024-07-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-27 | 2024-07-24 | 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 | 2024-06-27 | 2024-07-24 | N |
| Provide or obtain dental services for each resident. | Health | 2024-06-27 | 2024-07-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-06-27 | 2024-07-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-06-27 | 2024-07-24 | 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 | 2024-06-27 | 2024-07-24 | 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 | 2024-06-27 | 2024-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-27 | 2024-07-24 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-06-27 | 2024-07-24 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Meet other general requirements. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-06-21 | 2024-07-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-12 | 2024-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-12 | 2024-07-05 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-06-12 | 2024-07-05 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-06-12 | 2024-07-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-09 | 2024-05-24 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-05-09 | 2024-05-24 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-04-10 | 2024-04-10 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-04-10 | 2024-04-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-07 | 2024-03-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-16 | 2024-03-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-12 | 2023-11-08 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-05 | 2023-10-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-06 | 2023-08-02 | Y |
| 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 | 2023-07-06 | 2023-08-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-06 | 2023-08-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-13 | 2023-07-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-27 | 2023-03-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-27 | 2023-03-28 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-12 | 2023-03-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-12 | 2023-03-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-12 | 2023-03-17 | 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 | 2023-01-20 | 2023-03-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-20 | 2023-03-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-20 | 2023-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-20 | 2023-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-20 | 2023-03-01 | 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 | 2023-01-20 | 2023-03-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-20 | 2023-03-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-20 | 2023-03-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-01-20 | 2023-03-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-20 | 2023-03-01 | 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 | 2023-01-20 | 2023-03-01 | 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 | 2023-01-20 | 2023-03-01 | 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 | 2023-01-20 | 2023-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-20 | 2023-03-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-20 | 2023-03-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-20 | 2023-03-01 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-20 | 2023-03-01 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-20 | 2023-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-20 | 2023-03-01 | Y |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-01-12 | 2023-02-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-12 | 2023-02-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-12 | 2023-02-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-12 | 2023-02-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-12 | 2023-02-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-12 | 2023-02-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-12 | 2023-02-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-12 | 2023-02-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-08 | 2022-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-08 | 2022-12-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-29 | 2022-10-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-23 | 2022-09-05 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-23 | 2022-09-05 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-08-09 | 2022-08-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-10 | 2022-03-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-10 | 2022-03-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-01 | 2022-01-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-27 | 2019-11-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-09-27 | 2019-11-13 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-09-27 | 2019-11-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-27 | 2019-11-13 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-09-27 | 2019-11-13 | 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 | 2019-09-27 | 2019-11-13 | 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 | 2019-09-27 | 2019-11-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-27 | 2019-11-13 | 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 | 2019-09-27 | 2019-11-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-27 | 2019-11-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-09-27 | 2019-11-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-27 | 2019-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-27 | 2019-11-13 | 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 | 2019-09-27 | 2019-11-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-27 | 2019-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-27 | 2019-11-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-27 | 2019-11-13 | 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 | 2019-09-27 | 2019-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-27 | 2019-11-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-27 | 2019-11-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-27 | 2019-11-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-27 | 2019-11-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-27 | 2019-11-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-09-27 | 2019-11-13 | 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 | 2019-09-27 | 2019-11-13 | 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 | 2019-09-27 | 2019-11-13 | N |
| Provide or obtain dental services for each resident. | Health | 2019-09-27 | 2019-11-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-27 | 2019-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-27 | 2019-11-13 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-09-27 | 2019-11-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-09-27 | 2019-11-13 | N |
| Keep all essential equipment working safely. | Health | 2019-09-27 | 2019-11-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-23 | 2019-10-28 | 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 | 2019-09-23 | 2019-10-28 | 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 | 2019-09-23 | 2019-10-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-23 | 2019-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-23 | 2019-10-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-23 | 2019-10-28 | N |
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