A list of the most recent deficiencies for Sandstone Spring 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? |
|---|---|---|---|---|
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-21 | 2023-10-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-22 | 2023-10-24 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-22 | 2023-10-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-22 | 2023-10-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-22 | 2023-10-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-24 | 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 | 2023-09-22 | 2023-10-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-22 | 2023-10-24 | 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 | 2023-09-22 | 2023-10-24 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-22 | 2023-10-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-22 | 2023-10-24 | 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 | 2023-09-22 | 2023-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-10-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-22 | 2023-10-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-22 | 2023-10-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-08 | 2023-03-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-08 | 2023-03-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-02 | 2022-09-21 | Y |
| 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 | 2022-08-02 | 2022-09-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-02 | 2022-09-21 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-02 | 2022-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-02 | 2022-09-12 | 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 | 2022-08-02 | 2022-09-12 | 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 | 2022-08-02 | 2022-09-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-02 | 2022-09-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-02 | 2022-09-12 | 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 | 2022-08-02 | 2022-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-02 | 2022-09-12 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-08-02 | 2022-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-09-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-02 | 2022-09-12 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-02 | 2022-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-02 | 2022-09-12 | Y |
| Develop a communication plan. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-07-29 | 2022-09-08 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2022-08-02 | 2022-08-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-28 | 2022-02-24 | Y |
| 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 | 2022-01-28 | 2022-02-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-28 | 2022-02-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-28 | 2022-02-24 | Y |
| 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 | 2022-01-28 | 2022-02-24 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-05-07 | 2021-08-05 | Y |
| 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 | 2021-05-07 | 2021-08-05 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-05-07 | 2021-08-05 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-05-07 | 2021-08-05 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-07 | 2021-08-05 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-05-07 | 2021-06-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-07 | 2021-06-30 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-05-07 | 2021-06-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-05-07 | 2021-06-25 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-05-07 | 2021-06-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-07 | 2021-06-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-07 | 2021-06-04 | 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 | 2021-05-07 | 2021-05-28 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-07 | 2021-05-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-07 | 2021-05-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-07 | 2021-05-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-07 | 2021-05-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-31 | 2021-05-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-21 | 2019-08-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-14 | 2019-07-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-14 | 2019-07-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-14 | 2019-07-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-14 | 2019-07-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-14 | 2019-07-23 | 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 | 2019-06-14 | 2019-07-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-14 | 2019-07-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-14 | 2019-07-23 | 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 | 2019-06-14 | 2019-07-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-06-14 | 2019-07-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-14 | 2019-07-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-14 | 2019-07-08 | 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 | 2019-06-14 | 2019-07-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-14 | 2019-07-04 | 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 | 2019-06-14 | 2019-07-01 | 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 | 2019-06-14 | 2019-06-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-06-14 | 2019-06-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-14 | 2019-06-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-14 | 2019-06-17 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-06-14 | 2019-06-16 | 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 | 2019-06-14 | 2019-06-15 | N |
