A list of the most recent deficiencies for Tice Valley 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-12 | 2023-10-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-16 | 2023-09-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-16 | 2023-09-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-13 | 2023-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2023-01-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-22 | 2022-09-13 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-05-17 | 2022-07-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-17 | 2022-07-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-17 | 2022-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-17 | 2022-07-19 | Y |
| 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 | 2022-03-04 | 2022-04-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-04 | 2022-04-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-04 | 2022-04-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-04 | 2022-04-24 | 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 | 2022-03-04 | 2022-04-24 | 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 | 2022-03-04 | 2022-04-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-04 | 2022-04-24 | 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 | 2022-03-04 | 2022-04-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-04 | 2022-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-04 | 2022-04-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-01-20 | 2022-02-02 | N |
| Use approved construction type or materials. | Fire Safety | 2022-01-20 | 2022-02-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-20 | 2022-02-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-05 | 2019-07-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-05 | 2019-07-01 | 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 | 2019-04-04 | 2019-05-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-04 | 2019-05-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-04 | 2019-05-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-04 | 2019-05-03 | 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 | 2019-04-04 | 2019-05-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-04 | 2019-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-04 | 2019-05-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-04 | 2019-05-03 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2019-04-04 | 2019-05-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-04 | 2019-05-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-04 | 2019-05-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-04 | 2019-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-04 | 2019-05-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-04 | 2019-05-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-25 | 2018-08-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-25 | 2018-08-07 | 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 | 2018-05-24 | 2018-06-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-05-24 | 2018-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-24 | 2018-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-24 | 2018-06-24 | N |
