A list of the most recent deficiencies for Sweden Valley Manor. 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? |
|---|---|---|---|---|
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-10-20 | 2024-01-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-20 | 2024-01-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-26 | 2024-01-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-26 | 2024-01-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-26 | 2024-01-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-26 | 2024-01-11 | 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 | 2023-10-20 | 2023-12-11 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-20 | 2023-12-11 | 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 | 2023-10-20 | 2023-12-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-12-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-20 | 2023-12-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-20 | 2023-12-11 | 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 | 2023-10-20 | 2023-12-11 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-10-20 | 2023-12-11 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-10-20 | 2023-12-11 | 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 | 2022-11-01 | 2022-12-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-01 | 2022-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-01 | 2022-12-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-10-14 | 2022-12-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-14 | 2022-12-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-14 | 2022-12-09 | 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 | 2022-10-14 | 2022-12-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-14 | 2022-12-09 | 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 | 2022-10-14 | 2022-12-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-10-14 | 2022-12-09 | 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 | 2022-10-14 | 2022-12-09 | 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 | 2022-10-14 | 2022-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-14 | 2022-12-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-14 | 2022-12-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-23 | 2022-07-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-29 | 2021-12-15 | 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 | 2021-10-29 | 2021-12-15 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-10-29 | 2021-12-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-29 | 2021-12-15 | 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 | 2021-10-29 | 2021-12-15 | 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 | 2021-10-29 | 2021-12-15 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-10-29 | 2021-12-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-29 | 2021-12-15 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-28 | 2021-12-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-28 | 2021-12-02 | N |
