Deficiency Records for Surprise Valley Community Hospital D/p Snf
Updated as of May 01, 2021
This is not the most recent data for Surprise Valley Community Hospital D/p Snf. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2021-02-09 | 2021-03-03 | N |
| Provide immediate access to any resident. | Health | 2020-12-01 | 2020-12-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-07-03 | 2020-07-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-07-03 | 2020-07-24 | 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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-11 | 2019-10-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-07-17 | 2019-10-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-17 | 2019-10-08 | Y |
| 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-02 | 2019-08-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-02 | 2019-08-16 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2019-07-01 | 2019-08-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-01-31 | 2019-06-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-01-31 | 2019-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-31 | 2019-06-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-31 | 2019-06-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-02-01 | 2019-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-01 | 2019-05-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-12 | 2019-04-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-03-12 | 2019-04-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-02-04 | 2019-03-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-04 | 2019-03-20 | Y |
| 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 |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-08-24 | 2018-09-14 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-08-08 | 2018-08-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-06-29 | 2017-12-05 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-06-29 | 2017-12-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-06-29 | 2017-12-05 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-06-29 | 2017-12-05 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-06-29 | 2017-12-05 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-29 | 2017-12-05 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-06-29 | 2017-12-05 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-06-29 | 2017-11-14 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-06-29 | 2017-11-14 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2017-06-29 | 2017-11-14 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-06-29 | 2017-11-14 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-29 | 2017-11-14 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-29 | 2017-11-14 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-06-29 | 2017-11-14 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-06-29 | 2017-11-14 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-29 | 2017-11-14 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-06-29 | 2017-11-14 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-06-29 | 2017-11-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-06-29 | 2017-11-14 | N |
