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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-12 | 2024-03-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-02-12 | 2024-03-28 | 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 | 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 |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-25 | 2023-10-24 | 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 | 2023-08-25 | 2023-10-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
