CMS Inspection Results for PLEASANT VALLEY NURSING CENTER

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 08/07/2008 Fire Safety Survey for PLEASANT VALLEY NURSING CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
did not have a written emergency evacuation plan.	Isolated	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm

 

• 06/19/2008 Health Survey for PLEASANT VALLEY NURSING CENTER

Administration
Deficiency	Scope	Level of Harm
Choose a doctor to be the medical director.	Pattern	Actual harm
Get services outside the nursing home that meet professional standards.	Pattern	Actual harm
Be administered in a way that leads to the highest possible level of well being for each resident.	Pattern	Actual harm
Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
Quality Care
Deficiency	Scope	Level of Harm
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Pattern	Actual harm
Give professional services that meet a professional standard of quality.	Pattern	Actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm
Resident Rights
Deficiency	Scope	Level of Harm
Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States.	Pattern	Minimal harm or potential for actual harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm

 

• 06/14/2007 Health Survey for PLEASANT VALLEY NURSING CENTER

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Do a new assessment after any major change in a resident's physical or mental health.	Pattern	Potential for minimal harm
Check and update (if needed) each resident's assessment every 3 months.	Pattern	Potential for minimal harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm

 

• 06/14/2007 Fire Safety Survey for PLEASANT VALLEY NURSING CENTER

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm

 

• 06/15/2006 Fire Safety Survey for PLEASANT VALLEY NURSING CENTER

Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm

 

• 05/25/2006 Health Survey for PLEASANT VALLEY NURSING CENTER

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm