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Deficiency Records for Shepherd of The Valley Rehabilitation and Wellness
A list of the most recent deficiencies for Shepherd of The Valley Rehabilitation and Wellness. 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 Shepherd of The Valley Rehabilitation and Wellness. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-22 | 2024-04-26 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-02-01 | 2024-02-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-09 | 2023-12-08 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-10 | 2023-09-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-09-04 | 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 | 2023-08-10 | 2023-09-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-09-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-09-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-10 | 2023-09-04 | Y |
| 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 | 2023-08-10 | 2023-09-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-09-04 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-10 | 2023-09-04 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-10 | 2023-09-04 | Y |
| Meet other general requirements. | Fire Safety | 2023-08-09 | 2023-09-04 | 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 | 2023-08-09 | 2023-09-04 | 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 | 2023-08-09 | 2023-09-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-09 | 2023-09-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-09 | 2023-09-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-09 | 2023-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-09 | 2023-09-04 | N |
| Ensure gas cylinders are properly stored. | Fire Safety | 2023-08-09 | 2023-09-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-18 | 2023-07-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-18 | 2023-05-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-26 | 2022-10-26 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-31 | 2022-10-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-08-31 | 2022-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-31 | 2022-10-07 | 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 | 2022-08-31 | 2022-10-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-08-31 | 2022-10-07 | 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 | 2022-08-31 | 2022-10-07 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-08-31 | 2022-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-31 | 2022-10-07 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-31 | 2022-10-07 | 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 | 2022-08-31 | 2022-10-07 | 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 | 2022-08-31 | 2022-10-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-08-31 | 2022-10-07 | 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 | 2022-08-31 | 2022-10-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-08-31 | 2022-10-07 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-05-04 | 2022-05-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-03-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-29 | 2022-01-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-29 | 2022-01-28 | Y |
| 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 | 2021-08-05 | 2021-09-17 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-29 | 2021-08-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-07-29 | 2021-08-20 | 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 | 2021-07-29 | 2021-08-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-29 | 2021-08-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-05 | 2021-08-20 | 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 | 2021-08-05 | 2021-08-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-05 | 2021-08-20 | N |
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