A list of the most recent deficiencies for Valley Hill Health and Rehab Center. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-17 | 2023-11-20 | Y |
| 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 | 2024-01-17 | 2023-11-20 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-22 | 2023-05-18 | 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 | 2023-02-22 | 2023-05-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-22 | 2023-05-18 | 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 | 2023-02-22 | 2023-05-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-22 | 2023-05-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-20 | 2023-02-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-20 | 2023-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-20 | 2023-02-17 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-01-20 | 2023-02-17 | Y |
| Post nurse staffing information every day. | Health | 2023-01-20 | 2023-02-17 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-20 | 2023-02-17 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-20 | 2023-02-17 | Y |
| 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 | 2023-01-20 | 2023-02-17 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-01-20 | 2023-02-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-17 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-01-20 | 2023-02-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-20 | 2023-02-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-20 | 2023-02-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-20 | 2023-02-17 | Y |
| Report COVID19 data to residents and families. | Health | 2023-01-20 | 2023-02-17 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-20 | 2023-02-17 | 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 | 2021-12-21 | 2022-01-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-01 | 2021-08-06 | 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 | 2021-07-01 | 2021-08-06 | 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 | 2021-07-01 | 2021-08-06 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-07-01 | 2021-08-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-01 | 2021-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-01 | 2021-08-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-21 | 2021-08-06 | 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 | 2021-07-21 | 2021-08-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-17 | 2019-06-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-17 | 2019-06-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-17 | 2019-06-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-04-17 | 2019-06-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-17 | 2019-06-03 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-03-21 | 2019-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-21 | 2019-04-15 | 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 | 2019-03-21 | 2019-04-15 | N |
| Provide or obtain dental services for each resident. | Health | 2019-03-21 | 2019-04-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-21 | 2019-04-15 | N |
