A list of the most recent deficiencies for Pleasant Valley Healthcare 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-08 | 2022-11-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-08 | 2022-11-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-08 | 2022-11-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-08 | 2022-11-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-09 | 2022-11-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-09 | 2022-11-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-09 | 2022-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-09 | 2022-11-22 | 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 | 2022-11-09 | 2022-11-22 | 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 | 2022-11-09 | 2022-11-22 | 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 | 2022-11-09 | 2022-11-22 | N |
| Provide or obtain dental services for each resident. | Health | 2022-11-09 | 2022-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-09 | 2022-11-22 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-11-09 | 2022-11-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-09 | 2022-11-22 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-11-09 | 2022-11-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-11-09 | 2022-11-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-07-28 | 2021-09-21 | 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 | 2021-07-28 | 2021-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-28 | 2021-09-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-28 | 2021-09-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-28 | 2021-09-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-28 | 2021-08-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-28 | 2021-08-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-28 | 2021-08-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-28 | 2021-08-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-28 | 2021-08-06 | 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 | 2021-07-28 | 2021-08-06 | 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 | 2021-07-28 | 2021-08-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-28 | 2021-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-28 | 2021-08-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-01 | 2019-06-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-01 | 2019-06-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-01 | 2019-06-28 | 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 | 2019-05-01 | 2019-06-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-01 | 2019-06-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-01 | 2019-06-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-01 | 2019-06-28 | 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 | 2019-05-01 | 2019-06-28 | 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 | 2019-05-01 | 2019-06-28 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-05-01 | 2019-06-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-01 | 2019-06-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-05-01 | 2019-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-01 | 2019-06-28 | N |
| Dispose of garbage and refuse properly. | Health | 2019-05-01 | 2019-06-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-01 | 2019-06-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-05-01 | 2019-06-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-01 | 2019-06-28 | N |
