Deficiency Records for Pioneer Valley Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Pioneer Valley Health and Rehabilitation. 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 pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-21 | 2023-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | 2023-12-12 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-31 | 2023-07-21 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-07-31 | 2023-07-21 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-29 | 2023-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-29 | 2023-01-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-29 | 2023-01-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-29 | 2023-01-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-29 | 2023-01-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-22 | 2022-12-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-22 | 2022-12-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-22 | 2022-12-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-11-22 | 2022-12-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-22 | 2022-12-31 | 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 | 2022-11-22 | 2022-12-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-11-22 | 2022-12-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-22 | 2022-12-31 | 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 | 2022-11-22 | 2022-12-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-22 | 2022-12-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-22 | 2022-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-22 | 2022-12-31 | 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 | 2022-11-22 | 2022-12-31 | 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 | 2022-11-22 | 2022-12-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-22 | 2022-12-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-22 | 2022-12-31 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-11-22 | 2022-12-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-22 | 2022-12-31 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-22 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-22 | 2022-12-31 | N |
| 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 | 2022-09-21 | 2022-10-17 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-21 | 2022-10-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-17 | 2022-05-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-17 | 2022-05-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-17 | 2022-05-26 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-17 | 2022-05-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-04 | 2022-01-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-04 | 2022-01-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-04 | 2022-01-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-11-04 | 2022-01-14 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-11-04 | 2022-01-14 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-11-04 | 2022-01-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-04 | 2022-01-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-04 | 2022-01-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-04 | 2022-01-14 | N |
| 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 | 2021-11-04 | 2022-01-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-11-04 | 2022-01-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-11-04 | 2022-01-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-04 | 2022-01-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-04 | 2022-01-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-04 | 2022-01-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide activities to meet all resident's needs. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide appropriate foot care. | Health | 2021-11-04 | 2022-01-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-04 | 2022-01-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-11-04 | 2022-01-14 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-11-04 | 2022-01-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-04 | 2022-01-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-11-04 | 2022-01-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-04 | 2022-01-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-04 | 2022-01-14 | 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 | 2021-11-04 | 2022-01-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-11-04 | 2022-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2022-01-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-04 | 2022-01-14 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-11-04 | 2022-01-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-04 | 2022-01-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-04 | 2022-01-14 | N |
| Keep all essential equipment working safely. | Health | 2021-11-04 | 2022-01-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-17 | 2022-01-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-11-17 | 2022-01-01 | N |
| Develop a communication plan. | Fire Safety | 2021-11-17 | 2022-01-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-11-17 | 2022-01-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-17 | 2022-01-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-17 | 2022-01-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-10 | 2021-08-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-10 | 2021-08-04 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-06-10 | 2021-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-10 | 2021-08-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-10 | 2021-08-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-10 | 2021-08-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-10 | 2021-08-04 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-12-16 | 2020-01-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-12-16 | 2020-01-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-16 | 2020-01-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-12-16 | 2020-01-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-30 | 2019-12-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-30 | 2019-12-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-10-30 | 2019-12-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-30 | 2019-12-12 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-30 | 2019-12-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-30 | 2019-12-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-30 | 2019-12-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-30 | 2019-12-12 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-30 | 2019-12-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-30 | 2019-12-12 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-10-30 | 2019-12-12 | N |
