A list of the most recent deficiencies for Valley of The Moon Post Acute. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-28 | 2023-09-04 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-28 | 2023-09-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-28 | 2023-09-04 | 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 | 2023-07-28 | 2023-09-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-28 | 2023-09-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-08 | 2023-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-16 | 2020-01-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-10-16 | 2020-01-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-20 | 2019-12-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-16 | 2019-12-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-16 | 2019-12-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-16 | 2019-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-16 | 2019-12-13 | 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 | 2019-10-16 | 2019-12-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-16 | 2019-12-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-16 | 2019-12-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-16 | 2019-12-13 | 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 | 2019-10-16 | 2019-12-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-16 | 2019-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-16 | 2019-12-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-16 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-16 | 2019-12-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-16 | 2019-12-13 | N |
| Keep all essential equipment working safely. | Health | 2019-10-16 | 2019-12-13 | N |
| Have policies on smoking. | Health | 2019-10-16 | 2019-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-10 | 2019-01-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-10-26 | 2018-11-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-10-26 | 2018-11-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-26 | 2018-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-26 | 2018-11-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-26 | 2018-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-26 | 2018-11-20 | N |
