A list of the most recent deficiencies for Aspire of Pleasant 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 basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-11-21 | 2023-12-20 | 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 | 2023-11-21 | 2023-12-20 | 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 | 2023-11-21 | 2023-12-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-21 | 2023-12-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-11-21 | 2023-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-21 | 2023-12-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-21 | 2023-12-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-21 | 2023-12-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-21 | 2023-12-20 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-11-21 | 2023-12-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | 2023-12-20 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-11-21 | 2023-12-20 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-16 | 2023-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-16 | 2023-12-08 | 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 | 2023-11-16 | 2023-12-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-11-16 | 2023-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-16 | 2023-11-29 | N |
| Use approved construction type or materials. | Fire Safety | 2023-11-16 | 2023-11-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-16 | 2023-11-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-17 | 2023-03-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-17 | 2023-03-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-17 | 2023-03-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-17 | 2023-03-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-16 | 2023-03-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-16 | 2023-03-06 | 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 | 2023-02-16 | 2023-03-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-17 | 2023-03-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-17 | 2023-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-17 | 2023-03-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-17 | 2023-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-17 | 2023-03-06 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-02-17 | 2023-03-06 | N |
| Use approved construction type or materials. | Fire Safety | 2023-02-17 | 2023-03-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-13 | 2023-01-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-13 | 2023-01-10 | Y |
| 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 | 2022-12-13 | 2023-01-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-13 | 2023-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-13 | 2023-01-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-19 | 2023-01-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-19 | 2023-01-10 | Y |
| 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 | 2022-09-19 | 2023-01-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-19 | 2023-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2023-01-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-19 | 2022-10-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-19 | 2022-10-14 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-19 | 2022-10-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-19 | 2022-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-19 | 2022-10-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-19 | 2022-10-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-19 | 2022-10-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-19 | 2022-10-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-19 | 2022-10-14 | Y |
| 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 | 2022-09-19 | 2022-10-14 | Y |
| 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 | 2022-09-19 | 2022-10-14 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-09-19 | 2022-10-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-19 | 2022-10-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-19 | 2022-10-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-19 | 2022-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-06 | 2022-02-02 | Y |
| Post nurse staffing information every day. | Health | 2022-01-06 | 2022-02-02 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-01-06 | 2022-02-02 | Y |
| 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 | 2022-01-06 | 2022-02-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-06 | 2022-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-30 | 2022-02-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-29 | 2021-10-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-29 | 2021-10-28 | Y |
| 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 | 2021-09-29 | 2021-10-28 | Y |
| 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 | 2021-09-29 | 2021-10-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-22 | 2021-05-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-22 | 2021-05-07 | 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 | 2021-04-22 | 2021-05-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-22 | 2021-05-07 | 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 | 2021-04-26 | 2021-05-06 | 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 | 2021-04-26 | 2021-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-26 | 2021-05-04 | N |
