Deficiency Records for Surprise Valley Community Hospital D/p Snf
Updated as of March 01, 2024
A list of the most recent deficiencies for Surprise Valley Community Hospital D/p Snf. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-28 | 2023-12-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-05 | 2023-12-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-12 | 2023-05-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-10 | 2023-05-18 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-12 | 2022-07-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-05-12 | 2022-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-12 | 2022-07-13 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-05-12 | 2022-07-13 | 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 | 2022-05-12 | 2022-07-13 | 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 | 2022-05-12 | 2022-07-13 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-05-12 | 2022-07-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-12 | 2022-07-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-05-12 | 2022-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-12 | 2022-07-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-05-12 | 2022-07-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-12 | 2022-07-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-16 | 2022-06-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-05-16 | 2022-06-15 | N |
| Use approved construction type or materials. | Fire Safety | 2022-05-16 | 2022-06-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-16 | 2022-06-15 | 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 | 2022-05-16 | 2022-06-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-16 | 2022-06-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-18 | 2022-02-11 | Y |
| Keep all essential equipment working safely. | Health | 2022-01-12 | 2022-02-08 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-17 | 2019-10-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-07-17 | 2019-10-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-17 | 2019-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-17 | 2019-10-08 | 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 | 2019-07-17 | 2019-10-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-07-17 | 2019-10-08 | 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 | 2019-07-17 | 2019-10-08 | 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 | 2019-07-17 | 2019-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-17 | 2019-10-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-17 | 2019-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-17 | 2019-10-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-17 | 2019-10-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-17 | 2019-10-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-07 | 2019-08-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-08-07 | 2019-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-08-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-07 | 2019-08-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-07 | 2019-08-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-07 | 2019-08-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-07 | 2019-08-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-07-26 | 2018-09-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-26 | 2018-09-21 | 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 | 2018-07-26 | 2018-09-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-26 | 2018-09-21 | 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 | 2018-07-26 | 2018-09-21 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-07-26 | 2018-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-26 | 2018-09-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-07-26 | 2018-09-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-07-26 | 2018-09-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-26 | 2018-09-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-07-26 | 2018-09-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-08-08 | 2018-08-24 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-08-08 | 2018-08-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-08 | 2018-08-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-08 | 2018-08-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-08 | 2018-08-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-08 | 2018-08-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-08 | 2018-08-24 | N |
