Deficiency Records for Sandstone Spring Valley
Updated as of June 01, 2022
This is not the most recent data for Sandstone Spring Valley. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2021-01-14 | 2021-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-12-16 | 2021-02-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-12-16 | 2021-02-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-12-16 | 2021-02-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-09-15 | 2020-10-22 | N |
| Perform COVID19 testing on residents and staff. | Health | 2020-09-15 | 2020-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-18 | 2020-10-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-29 | 2020-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-04-30 | 2020-05-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-14 | 2020-02-10 | Y |
| 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 |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Develop a communication plan. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-19 | 2018-06-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-04-20 | 2018-06-13 | 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 | 2018-04-20 | 2018-06-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-04-20 | 2018-06-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-20 | 2018-06-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-20 | 2018-06-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-20 | 2018-06-13 | 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 | 2018-04-20 | 2018-06-13 | 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 | 2018-04-20 | 2018-06-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-04-20 | 2018-06-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-04-20 | 2018-06-13 | 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 | 2018-04-20 | 2018-06-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-20 | 2018-06-13 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-07 | 2017-04-14 | N |
| Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. | Health | 2017-03-07 | 2017-04-14 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-07 | 2017-04-14 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-03-07 | 2017-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-07 | 2017-04-14 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-03-07 | 2017-04-14 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-03-07 | 2017-04-14 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-03-07 | 2017-04-14 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-07 | 2017-04-14 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-03-07 | 2017-04-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-03-07 | 2017-04-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-03-03 | 2017-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-03-03 | 2017-04-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-03-03 | 2017-04-14 | N |
