A list of the most recent deficiencies for Our Lady of The 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-25 | 2023-10-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-25 | 2023-10-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-25 | 2023-10-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-29 | 2021-06-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-29 | 2021-06-15 | 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 | 2021-04-15 | 2021-05-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-15 | 2021-05-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-15 | 2021-05-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-05-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-15 | 2021-05-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-15 | 2021-05-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-04-15 | 2021-05-25 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-15 | 2021-05-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-15 | 2021-05-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-04-15 | 2021-05-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-15 | 2021-05-25 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-22 | 2019-06-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-22 | 2019-06-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-22 | 2019-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-22 | 2019-06-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-22 | 2019-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-08 | 2019-05-17 | 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 | 2019-04-08 | 2019-05-17 | 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 | 2019-04-08 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-08 | 2019-05-17 | N |
| Use approved construction type or materials. | Fire Safety | 2018-03-15 | 2018-04-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-15 | 2018-04-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-03-15 | 2018-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-15 | 2018-04-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-15 | 2018-03-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-02-15 | 2018-03-30 | 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 | 2018-02-15 | 2018-03-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-15 | 2018-03-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-15 | 2018-03-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-02-15 | 2018-03-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-02-15 | 2018-03-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-02-15 | 2018-03-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-15 | 2018-03-30 | 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 | 2018-02-15 | 2018-03-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-02-15 | 2018-03-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-02-15 | 2018-03-30 | N |
