South Valley Post Acute Rehabilitation

Nursing and Physician Services Deficiencies

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.

Construction Deficiencies

Meet other general requirements.

Egress Deficiencies

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.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Pharmacy Service Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

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.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

A complaint survey, prompted by complaint #CO#35636, #CO35988, #CO36012 and Incident #34978was conducted on 5/15/24 to 5/16/24. One deficiency was cited. Based on observations and interviews, the facility failed to maintain a clean and sanitary homelike environment in one out of three units reviewed.Specifically, the facility failed to ensure the residents experienced a clean and sanitary homelike environment with living spaces free from odors, soiled and damaged floors and walls, chipped paint, clean living common area spaces and availability of clean linens.Findings include:I. Policy and proceduresThe Quality of Life Homelike Environment policy, revised December 2023, was received from the director of nursing (DON) on 5/16/24 at 6:57 p.m. It read in pertinent part,"Staff shall provide person centered care that emphasizes the resident' s comfort, independence and personal needs. "The characteristics of the homelike environment are: -Clean, sanitary, orderly environment; -Comfortable yet adequate lighting; -Personalized furniture and room arrangements; and, -Clean, bed and bath linens."II. ObservationsDuring the survey, from 5/15/24 to 5/16/24, the second floor unit environment common areas were observed on several occasions. The following conditions were observed: -The hallway walls had a thick dried, blackish-brown substance along the bottom of the walls in the hallways.-The floor in the common area outside of the elevator was soiled with bread crumbs, a sticky white substance, and pieces of brown matter. -The dining room tables were soiled with a sticky dried clearish-yellow substance. -There were three large brown recliner chairs observed in the common area. The artificial leather upholstering was cracked and had peeled off on all of the chair' s armrests making them impossible to clean and disinfect properly. The seat cushions and leg rests of the chairs had holes in them and the stuffing was coming out. Pieces of the chair remained from the chairs all over the floor.-The dining area just off the elevators had a strong smell of body odor. The floor was heavily soiled under each table with black stains and large areas of a dried clear substance. -The edges of the floor at the wall were heavily soi..