A list of the most recent deficiencies for Pavilion at Glacier 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? |
|---|---|---|---|---|
| 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 | 2024-01-16 | 2024-02-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-16 | 2024-02-05 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-13 | 2024-01-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-13 | 2024-01-08 | 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 | 2023-12-13 | 2024-01-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2024-01-08 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-13 | 2024-01-08 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-12-13 | 2024-01-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-13 | 2024-01-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-13 | 2024-01-05 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-12-13 | 2024-01-04 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-12-13 | 2023-12-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-13 | 2023-12-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-12-13 | 2023-12-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-13 | 2023-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-13 | 2023-12-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-13 | 2023-12-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-10-04 | 2023-10-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-04 | 2023-10-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-04 | 2023-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-10-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-04 | 2023-10-27 | Y |
| 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 | 2023-10-04 | 2023-10-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-31 | 2023-06-26 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-31 | 2023-06-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-31 | 2023-06-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-31 | 2023-06-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-31 | 2023-06-26 | Y |
| 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 | 2023-05-31 | 2023-06-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-31 | 2023-06-26 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-05-31 | 2023-06-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-31 | 2023-06-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-31 | 2023-06-26 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-17 | 2023-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-17 | 2023-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-17 | 2023-02-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-11 | 2022-11-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-11 | 2022-11-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-11 | 2022-11-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-11 | 2022-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-11 | 2022-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-11 | 2022-11-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-11 | 2022-11-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-11 | 2022-11-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-11 | 2022-11-04 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-17 | 2022-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-17 | 2022-11-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-17 | 2022-10-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-17 | 2022-10-27 | 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 | 2022-10-17 | 2022-10-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-10-17 | 2022-10-18 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-10-17 | 2022-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-09 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-29 | 2021-07-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-29 | 2021-07-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-29 | 2021-07-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-29 | 2021-07-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-29 | 2021-07-22 | 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 | 2021-07-01 | 2021-07-21 | Y |
| 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 | 2021-07-01 | 2021-07-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-31 | 2021-04-21 | Y |
