Deficiency Records for West Valley Subacute and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for West Valley Subacute and Nursing Center. 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 | 2023-11-30 | 2023-12-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-04 | 2023-09-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-04 | 2023-09-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-25 | 2023-05-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-10 | 2023-02-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-26 | 2022-12-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-25 | 2022-07-25 | 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 | 2022-07-25 | 2022-07-25 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-31 | 2022-02-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-31 | 2022-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-28 | 2022-02-17 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-14 | 2022-02-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-14 | 2022-02-14 | 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 | 2022-01-14 | 2022-02-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-14 | 2022-02-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-01-14 | 2022-02-14 | N |
| Provide activities to meet all resident's needs. | Health | 2022-01-14 | 2022-02-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-14 | 2022-02-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-14 | 2022-02-14 | 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 | 2022-01-14 | 2022-02-14 | 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 | 2022-01-14 | 2022-02-14 | 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 | 2022-01-14 | 2022-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-14 | 2022-02-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-14 | 2022-02-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-14 | 2022-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-02-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-24 | 2022-02-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-28 | 2022-01-28 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-13 | 2022-01-28 | 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 | 2022-01-13 | 2022-01-28 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-13 | 2022-01-28 | 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 | 2021-12-23 | 2022-01-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-17 | 2021-12-24 | Y |
| Post nurse staffing information every day. | Health | 2021-12-16 | 2021-12-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-02 | 2021-09-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-26 | 2021-07-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-07 | 2021-06-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-07 | 2021-06-17 | Y |
| 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 | 2021-05-24 | 2021-06-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-04 | 2021-05-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-23 | 2021-05-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-23 | 2021-05-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-23 | 2021-05-13 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-04-23 | 2021-05-13 | Y |
| 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 | 2021-04-23 | 2021-05-13 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-23 | 2021-05-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-16 | 2021-04-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-16 | 2021-04-29 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-08 | 2019-11-12 | N |
| 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 | 2019-10-08 | 2019-11-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-08 | 2019-11-12 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-08 | 2019-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-08 | 2019-11-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-08 | 2019-11-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-08 | 2019-11-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-08 | 2019-11-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-08 | 2019-11-12 | 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 | 2019-10-08 | 2019-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-08 | 2019-11-12 | N |
| Keep all essential equipment working safely. | Health | 2019-10-08 | 2019-11-12 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-04 | 2019-10-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-04 | 2019-10-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-04 | 2019-10-21 | 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 | 2019-10-04 | 2019-10-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-04 | 2019-10-21 | 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 | 2019-10-04 | 2019-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-04 | 2019-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-04 | 2019-10-21 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-10-04 | 2019-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-04 | 2019-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-04 | 2019-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-04 | 2019-10-21 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-10-19 | 2018-12-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-19 | 2018-12-01 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2018-10-19 | 2018-12-01 | 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 | 2018-10-19 | 2018-12-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-10-19 | 2018-12-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-10-19 | 2018-12-01 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-10-19 | 2018-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-19 | 2018-12-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-10-19 | 2018-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-19 | 2018-12-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-10-19 | 2018-12-01 | 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 | 2018-10-19 | 2018-11-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-19 | 2018-11-19 | 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 | 2018-10-19 | 2018-11-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-19 | 2018-11-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-19 | 2018-11-19 | 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 | 2018-10-19 | 2018-11-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-19 | 2018-11-19 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-10-19 | 2018-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-19 | 2018-11-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-10-19 | 2018-11-19 | 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 | 2018-10-19 | 2018-11-19 | 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 | 2018-10-19 | 2018-11-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-19 | 2018-11-19 | 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 | 2018-10-19 | 2018-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-19 | 2018-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-19 | 2018-11-19 | N |
