A list of the most recent deficiencies for Buffalo Valley Lutheran Villag. 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? |
|---|---|---|---|---|
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-09-13 | 2023-11-12 | 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 | 2023-09-13 | 2023-11-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-01 | 2023-10-17 | 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 | 2023-09-01 | 2023-10-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-01 | 2023-10-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-01 | 2023-10-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-01 | 2023-10-17 | 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 | 2023-09-01 | 2023-10-17 | 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 | 2023-09-01 | 2023-10-17 | N |
| Post nurse staffing information every day. | Health | 2023-09-01 | 2023-10-17 | 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 | 2023-09-01 | 2023-10-17 | N |
| Provide or obtain dental services for each resident. | Health | 2023-09-01 | 2023-10-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-01 | 2023-10-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-21 | 2023-01-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-21 | 2023-01-30 | Y |
| 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 | 2022-09-30 | 2022-11-29 | 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 | 2022-09-30 | 2022-11-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-30 | 2022-11-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-30 | 2022-11-29 | 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 | 2022-09-30 | 2022-11-29 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-09-30 | 2022-11-29 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-09-30 | 2022-11-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-30 | 2022-11-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-30 | 2022-11-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-30 | 2022-11-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-30 | 2022-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-11-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-30 | 2022-11-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-30 | 2022-11-29 | 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 | 2022-09-30 | 2022-11-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-30 | 2022-11-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-30 | 2022-11-29 | 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 | 2022-09-30 | 2022-11-29 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-09-20 | 2022-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-20 | 2022-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-20 | 2022-11-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-08 | 2021-11-30 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-10-08 | 2021-11-30 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-08 | 2021-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-08 | 2021-11-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-08 | 2021-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-08 | 2021-11-30 | 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 | 2021-10-08 | 2021-11-30 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-04-07 | 2021-05-18 | Y |
