Valley Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and records review, the facility failed to obtain initial screening for rehabilitative services for one of 20 sampled residents, (Resident 455) upon admission. This failure had the potential to result in a decrease in resident's range of motion (the extent and degree of movement a joint or series of joints can achieve) mobility and muscle strength. Findings: During a review of Resident 455's admission Record, (a document showing a summary of the resident's information), dated 3/5/25, indicated, Resident 455 was admitted to the facility on [DATE]. During a review of Resident 455's History and Physical Examination, (H&P) dated 1/29/25, indicated, Resident 455 had a past medical history of Cerebrovascular accidents (CVA), (commonly known as stroke, occur when blood flow to the brain is interrupted, leading to brain damage), Hemiplegia ( a condition characterized by paralysis or severe weakness on one side of the body). H&P indicated Resident 455 has the capacity to make needs known…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. Licensed Vocational Nurse (LVN) 2 did not perform proper hand hygiene (the process of cleaning one's hands to remove dirt, germs, and microorganisms with soap and water or an alcohol based foam or gel) during medication administration for Residents 48, 58, and 59. 2. Certified Nurse Assistant (CNA) 1 failed to perform hand hygiene and don (put on) gloves and an isolation gown before entering Resident 355 room, who was on Contact Isolation Precautions (a set of precautions used to stop the spread of germs from a patient to others). 3. Two sharps containers (used for safe disposal of used needles and syringes) were observed filled past the full line indicator (a line marker indicating the container needs to be replaced) for two of three sampled medication carts (Carts 2 & 3). This had the potential risk for infections related to needlestick injuries (injuries caused by punctures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for all four sampled residents (Residents 1, 2, 3, and 4). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1, 2, 3, and 4) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1's admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included metabolic encephalopathy (brain is not working properly because of imbalance in the body's chemicals). During a review of the clinical record for Resident 1's, the Brief Interview for Mental Status (BIMS- screening tool to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to adhere to its food-related garbage disposal policy when two outdoor dumpsters were left open. This failure had the potential to attract vermin (pest or animals that spread diseases) which could pose a significant health risk to the 100 clinically compromised residents currently residing in the facility. Findings: During a concurrent observation and interview, on November 23, 2024, at 1:20 p.m., with Director of Staff Developer (DSD) 1, I brought her to the garbage disposal area outside the facility and showed her that two of the dumpsters were open. During an interview on November 25, 2024, at 3:54 p.m., with Administrator (ADM) 1, I informed ADM 1 that during my inspection of the dumpsters on November 23, 2024, I discovered that two of the dumpsters was left uncovered. I mentioned to ADM 1 that it should be closed at all times with tight fitting lids if it is not in continuous use, in accordance with facility policy. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy when a staff did not notify the responsible party of blisters observed on the right hand of one of three sampled residents (Resident 1) and document in the medical record. This had the potential to exclude the family and responsible party of (Resident 1) to actively participate in the plan of care related to the resident's change of condition. Findings: During a review of Resident 1 ' s Face Sheet (general demographics) on August 28, 2024, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included Alzheimer ' s (a brain condition that slowly destroys memory), dementia (a condition of loss of memory and thinking caused by brain damage of blood flow to the brain). During a review of Resident 1 ' s Face Sheet indicated, Responsible Party, Wife [Name of wife] with phone number provided. During a review of Resident 1 ' s History and Physical Examination (H&P), the H&P dated July 16, 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. The call lights are answered in a timely manner for two of three residents (Resident 2 and Resident 3). This failure placed two clinically compromised Residents (Resident 2 and Resident 3) health and psychosocial (emotional) status at risk when their need for nursing care was not met timely. 2. Nursing staff monitor one of three residents (Resident 1) every shift for hydration after a change of condition. This failed practice had the potential for a delay in treatment and placed Resident 1 at risk for dehydration. Findings: 1. During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was admitted on [DATE], with diagnoses which included: Multiple sclerosis (disease of the nervous system, which gradually makes a person weaker), paraplegia (inability to voluntarily move the lower parts of the body) and pressure ulcer (injuries to skin and underlying tissue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess and develop a plan of care with interventions to preventing and developing pressure ulcer for one of three residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk. When Resident 1 developed a facility acquired pressure ulcer. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: acute respiratory failure with hypoxia (shortness of breath), chronic obstructive pulmonary disease (block airflow, difficult to breathe, congestive heart failure (heart doesn't pump blood as well), end stage renal disease (kidney lose ability to function). During concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON), reviewed and verified the following: 1. Wound Assessment Report October 03, 2023 . (Vascular access site, peripherally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure treatments for pressure ulcers (bed sore) were completed for one of 3 sampled residents (Resident 1) when staff did not follow the facility policy and document that the physician ordered treatments were completed daily for the month of July 2023. These failures contributed to the decline of Resident 1's pressure ulcers thereby affecting his physical and psychosocial well-being. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Pressure ulcer (sustained pressure on an area of the body) of sacral region, Pressure ulcer of back, buttock, hip, stage 4 (deep wound that may impact tissue, ligament and bone), and paraplegia (paralysis of the legs and lower body.) During an observation and interview with Resident 1on August 18, 2023, at 1:37 PM, Resident 1 stated, They let me get a bunch of bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility did not maintain professional standards for food service safety when: 1. There was five shelves that had a rust colored substance on the reach-in refrigerator, and four shelves with rust colored substance in the walk-in refrigerator, this had the potential for the rust colored substance to be transferred to the foods stored on the shelves. 2. There was a personal item stored in the food prep area, this had the potential to contaminate food during food prep. 3. The large ice machine had black smudges on the top ceiling of the ice bin. This had the potential to contaminate the ice. These failures to ensure a safe and sanitary kitchen resulted in the increased risk of resident harm from food borne illness to a population of 90 immuno-compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Service Supervisor (DSS), on August 1, 2022, at 8:24 AM, the reach-in refrigerator was observed to have five shelves with a rust colored substance and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility did not maintain equipment in safe operating conditions when: 1. The reach-in refrigerator was leaking, and this had the potential to contaminate food and effect the proper functioning of the refrigerator. 2. The walk-in refrigerator was leaking and had ice buildup on a pipe, this had the potential to affect the proper functioning of the refrigerator 3. The freezer had ice chunks on the pipe, which had the potential to affect the proper functioning of the freezer. These failures to maintain equipment had the potential to place the health of the # residents who received food from the kitchen at risk since refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. Findings: 1. During a concurrent observation and interview on August 1, 2022, at 9:25 AM, with the Dietary Service Supervisor (DSS), the reach-in refrigerator near the handwashing sink, was very wet inside and was leaking water from the pipe connected to the fan.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure safe and effective pharmaceutical services for a universe of 95 residents when: 1. For Resident 54, the facility could not demonstrate controlled substance accountability for liquid Ativan (anti-anxiety medication) controlled substances (highly regulated drugs due to potential for abuse or misuse). This occurred when the quantity dispensed by the Pharmacy did not match the starting amount indicated on the resident's controlled substance record (narcotic count sheet). This failure had the potential to result in drug diversion (illegal use of narcotics) and/or inadequate controlled substances accountability. 2. For one of six medication pass observation residents (Resident 491), insulin (drug to lower blood sugar levels) Apidra (mealtime insulin) was not administered in accordance with manufacturer's instructions. This failure had the potential to result in ineffective drug treatment and/or suboptimal clinical outcomes. 3. The intravenous (IV - into the resident's vein) Emergency Kit (E-Kit) was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility did not follow their daily menu for lunch when, on August 1, 2022, at 12:04 PM, three residents on renal diets (a diet low in sodium, phosphorus, and protein for people with kidney disease) received two ounces of protein instead of three ounces. This failure had the potential to affect the nutritional status of the three residents on a renal diet. Findings: During concurrent observation and interview on August 1, 2022, at 12:25 PM, in the kitchen during tray-line (when the cook serves the food onto each resident's plate) [NAME] 1 placed five meatballs on the plate for the residents on renal diets. [NAME] 1 weighed the five meatballs and stated that the scale read two ounces. During an interview with the DSS, on August 1, 2022, at 12:40 PM, when asked how many meatballs it takes to weigh three ounces, she stated, the meatballs come in different sizes, so they would need to be weighed to ensure that the correct portion is served. During a review of the Cooks Spreadsheet, dated 8/1/2022, indicated that the renal diet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe infection prevention and control program when: 1. Treatment Nurse 1 (TN 1) did not wash her hands with soap and water after performing wound care for Resident 141 who was on contact isolation precautions (to prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of a gown and gloves on every entry into a resident's room) for an infection with Clostridium difficile (C. diff-a bacterium that causes diarrhea and colitis-an inflammation of the colon). 2. A laundry staff (LS 1) did not follow the manufacturer's guidelines for the disinfectant used to disinfect the dirty linen carts and barrels. 3. A Certified Nurse Assistant (CNA 4) did not observe hand hygiene after touching and disposing soiled linens. 4. For Resident 491, during medication pass observation, the licensed vocational nurse (LVN 1) did not perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 12) was treated with respect and dignity when the resident, who was unable to feed himself, was stood over by a Certified Nursing Assistant (CNA 1) while assisting Resident 12 to eat. This failure had the potential to cause the resident to feel humiliated having to look up at CNA 1 while having food spooned into his mouth and placed him at risk for aspiration. Findings: A review of Resident 12's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 12 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's disease (a progressive brain disease that destroys memories and thinking skills). During an observation and interview with Resident 12 and CNA 1 on August 1, 2022, at 12:16 PM, Resident 12 was seated in a wheelchair in the dining room and positioned at a dining table. No other residents were seated at the table. A food tray was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to discuss and provide information on advanced directives for two of two sampled residents (Residents 85 and 88). This failure had the potential to cause Residents 85 and 88's values and desires related to end-of-life care not to be carried out. Findings: 1. A review of Resident 85's face sheet (a document that gives a summary of resident's information), undated, indicated a re-admission date of July 2, 2022, with a diagnosis of non-traumatic subarachnoid hemorrhage from unspecified intracranial artery (bleeding in the space that surrounds the brain, not caused by trauma). A review of Resident 85's Physician Orders for Life-Sustaining Treatment (POLST) dated April 12, 2022, was conducted. Under section D: Information and Signatures, the area where the POLST and advanced directives were supposed to be discussed was blank. The Section Additional Contact, was blank. The POLST indicated Resident 85's nephew had signed the document. During an interview with Resident 85 on August 1, 2022, at 2:30 PM, Resident 85 stated he did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for one of one resident (Resident 83) when Resident 83 refused nail grooming. This failure had the potential to miss opportunities to identify alternatives and consequences of refusing care that can negatively impact Resident 83. Findings: During an observation on August 1, 2022, at 11:21 AM, Resident 83 was observed in bed, noted with long and dirty nails on the left index, middle and ring finger, and a long, dirty nail on the right thumb. During a concurrent interview and record review, with the Minimum Data Set (MDS- a computerized assessment tool) Coordinator (staff responsible for clinical assessment of all residents in Medicare or Medicaid certified nursing home), on August 3, 2022, at 10:45 AM, Resident 83's face sheet (a document that contains resident demographics and diagnoses) indicated he was admitted on [DATE]. The MDS Coordinator stated that nail grooming was part of personal hygiene they assess to see if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary treatment and service to promote healing of pressure ulcers was provided for one of three residents observed (Resident 293) when Resident 293's left and right heels were not floated (legs elevated on pillow to keep heels from touching the bed), to relieve pressure as indicated in the care plan. This failure had the potential to lead to worsening of the wounds and delay wound healing which would further compromise the health and welfare of Resident 293. FINDINGS: During a wound treatment observation on August 2, 2022, at 11:42 AM, in Resident 293's room with Treatment Nurse 1 (TN 1), Resident 293 was lying in bed on his back. Resident 293's left and right heel pressure ulcers with dressings, were resting directly on his mattress, and not floated to relieve pressure. During the dressing change, the old dressing to the right heel had blood and was stuck to the wound as TN 1 tried to remove the dressing. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure all residents received adequate supervision to prevent accidents when, one of two residents (Resident 23) was reviewed for falls. The facility failed to implement the interventions of placing the Resident 23's bed in its lowest position and did not provide a fall mat. These failures had the potential for further falls, serious injuries, and even death. Findings: During a concurrent observation and interview on August 2, 2022, at 3:00 PM, in Resident 23's room, Resident 23 was sitting upright in bed and leaning towards his left side. Resident 23's bed was not placed in the low position and there was no fall mat noted on the floor. Resident 23 stated he had a fall recently but could not remember the exact date. Resident 23 further stated his bed was not always in the lowest position. During a record review of facility's Interdisciplinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pain was assessed and managed before, during and after wound care, for one of one sampled resident (Resident 141). This failure caused Resident 141 to suffer pain at a level that was unacceptable to the resident. Findings: A review of Resident 141's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 141 was admitted to the facility on [DATE], with a diagnosis of encounter for surgical aftercare following surgery on the digestive system. A review of Resident 141's Care Plan titled, Surgical Incision/Wound mid [middle] lower abdomen, dated July 30, 2022, indicated, Intervention: Administer pain medication prior to initiating treatment. A review of Resident 141's Care Plan titled, Pressure Ulcer [a wound caused by pressure]: Sacrum [a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis] (DTI) [Deep Tissue Injury], dated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the observation, interview, and record review, the facility failed to ensure medications were appropriately labeled in accordance with standards of practice and/or policy when: For Resident 43,70, and 295, four insulin (drug used to lower blood sugar) pens were observed stored opened and undated in the Medication Carts 2 & 3 as follows : a. For Resident 70, on Medication Cart 3, there was a lispro insulin pen was opened and undated. b. For Resident 295, on Medication Cart 2, there was an aspart insulin pen was opened and undated. c. For Resident 43, on Medication Cart 2, there were two glargine insulin pens opened and undated. These failures placed Residents 43, 70, and 295 at risk for receiving ineffective or outdated medications. Finding: a. During a concurrent observation and interview on August 1, 2022, at 12:02 PM, an inspection of Med Cart 3 was conducted with Licensed Vocational Nurse 6 (LVN 6). An insulin lispro pen for Resident 70 was stored opened and undated in the medication cart. LVN 6 acknowledged the opened and undated insulin lispro pen stored in the cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance for dental services needed for one of one sampled resident (Resident 58) when they did not follow up on the status of eligibility for dentures for Resident 58 who was missing upper and lower teeth. This failure prevented Resident 58 from obtaining an identified need for dental services in a timely manner. Findings: During an observation on August 1, 2022, at 9:43 AM, Resident 58 was seen inside his room, observed with missing upper and lower teeth. Resident 58 stated he was interested in how he could get dentures. During a review of Resident 58's medical record on August 3, 2022, at 10:14 AM, Resident 58's face sheet (a document that contains resident demographics and diagnoses) indicated he was admitted [DATE]. Further record review indicated Resident 58 had his last dental consult on December 16, 2021. During an interview on August 3, 2022, at 11:15 AM, the dentist stated during his last visit on December 16, 2021,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure collaboration and coordination with contracted hospice services for one of one sampled resident (Resident 14) when there was no current hospice plan of care available in the facility and there was no schedule on when skilled nursing, hospice aide, social worker or spiritual counselor visits would be conducted. This failure had the potential to cause Resident 14 not to receive hospice services based on a comprehensive person-centered care plan. Findings: A review of Resident 14's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of July 28, 2020, with a diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). A review of Resident 14's facility care plan titled, Receiving Hospice Care from [name of hospice] for routine level of care with primary dx [diagnosis] of Parkinson's disease, dementia [a group of thinking and social symptoms that interferes with daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices for dietary services when: 1) Plastic pitchers used for food service were not air dried and stored for use. 2) Bowls used for food service were found dirty and stacked for use. 3) The food preparation sink had no air gap and were plumed directly to the waste water system. This had the potential for waste water to enter and contaminate the food preparation sink. These failures had the potential to contaminate resident food sources that can cause foodborne illness (a disease caused by consuming contaminated food or drink), in a vulnerable population of 90 out of 94 residents receiving dietary services, resulting in severe resident harm, and even death. Findings: 1. During an observation and concurrent interview on March 9, 2020, at 8:45 AM, Fifteen out of 20 plastic pitchers were found to be clean and stacked wet for resident used for juice or water, observed with the Dietary Supervisor (DS), The DS stated all dishes and containers should be air…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to notify the resident and document in the clinical record for one of six sampled residents (Resident 39) when the pain medication order was changed. This failure resulted in Resident 39 not being aware of change of pain medication order which could result in inappropriate pain management. Finding: During a record review of Resident 39's face sheet (a document containing basic information about the resident) indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included muscle weakness. During a review of Resident 39's physicians order dated February 25, 2020, indicated, Cut down hydro-codone (a type of pain medication) to 10/325 mg (milligram-a unit of measurement) every 8 hours as needed. During a review of Resident 39's progress notes for the month of February 2020, there is no documented evidence Resident 39 was notified about the change of pain medication order. During an interview with Resident 39 on March 12, 2020 at 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure for one of 39 sampled residents (Resident 253) resident 253 medical records were secured to ensure confidentiality. This failure had the potential to allow unauthorized staff or visitors to access resident's confidential medical and personal information. Findings: During an observation on March 9, 2020, at 3:26 PM, at the nurse's station a computer was left opened and logged in to with Resident 253's general progress notes (a medical record where health care professionals record details to document a resident's clinical status) with Resident 253's name, date of birth and medical diagnoses. During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 1), on March 9, 2020, at 3:31 PM, LVN 1 confirmed Resident 253's medical record with general progress notes name, date of birth , and medical diagnoses of Resident 253 was left opened and unattended. During an interview with the Director of Nursing (DON) on March 12, 2020, at 4:01 PM, the DON stated staff are expected to minimize or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure an admission Minimum Data Set (MDS- facility assessment tool) assessment was completed according to the Centers of Medicare and Medicaid Services (CMS) timeframes, for one of three sampled residents (Resident 1). This failure had the potential for inadequate monitoring of Resident 1's progress and lack of resident specific information to CMS for payment and quality measure monitoring. Findings: During a review of Resident 1's Face Sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (UTI- infection that affects the urinary system with painful and burning urination), generalized muscle weakness and hypothyroidism (low level of thyroid hormone level in the body). During a concurrent interview and record review with the MDS Nurse on March 13, 2020, at 10:15 AM, reviewed Resident 1's admission MDS assessment dated [DATE]. The MDS Nurse confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a quarterly comprehensive assessment was completed and submitted to the Centers of Medicare and Medicaid Services (CMS) timeframes, for one of three residents (Resident 1). This failure had the potential for inadequate monitoring of Resident 1's progress and lack of resident specific information to CMS for payment and quality measure monitoring. Findings: During a review of Resident 1's Face Sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (UTI- infection that affects the urinary system with painful and burning urination), generalized muscle weakness and hypothyroidism (low level of thyroid hormone level in the body). During a review of facility's undated untitled document indicated, Resident 1's quarterly Minimum Data Set (MDS- a facility assessment tool) assessment with a current target date of December 18, 2019, was completed late. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Minimum Data Set [MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA)] assessment was conducted and submitted to the Centers of Medicare and Medicaid Services (CMS) within set timeframes, for one of three residents (Resident 1). This failure had the potential for inadequate monitoring of Resident 1's progress and lack of resident specific information to CMS for payment and quality measure monitoring. Findings: During a review of Resident 1's Face Sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (UTI- infection that affects the urinary system with painful and burning urination), generalized muscle weakness and hypothyroidism (low level of thyroid hormone level in the body). During a concurrent interview and record review with the MDS Nurse on March 13, 2020, at 10:15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS- facility assessment tool) assessments for one of three residents (Resident 52) when Resident 52's MDS assessment indicated resident had anticoagulants (blood thinners) for seven days. This failed practice had the potential to result in unmet care needs for Resident 52, which can potentially jeopardize health and safety of Resident 52. Findings: During an observation and interview, on March 9, 2020, at 8:30 AM, in Resident 52's room Resident 52 was sitting in her bed watching TV. Resident 52 was alert, oriented and was able to communicate her needs. Resident 52 stated she was not on any blood thinners. During a review of Resident 52's clinical record, Face Sheet (contains demographic information) indicated, Resident 52 was admitted on [DATE], with a diagnoses which included hemiplegia (total or partial paralysis of one side of the body from any disease or injury) and cerebral infarction (area of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of six sampled residents (Resident 8) physician's order were followed when: 1. Resident 8's physician order for Range of Motion (ROM-a type of exercise to keep the muscles active) was not carried out by nursing services and communicated to Restorative Nursing Assistant (RNA 1- a member of the nursing department trained to provide ROM services to residents) 2. Resident 8's physician's order to monitor oxygen saturation (the amount of oxygen in the blood) every shift was not being done. This failure had the potential to result in the delay of therapy treatment, and to adversely affect the health and safety of Resident 8. Findings: 1. During a record review of Resident 8's face sheet (a document which contains basic information about the resident), indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included muscle weakness. During a review of Resident 8's physician order dated March 6, 2020, indicated, Please do…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure a licensed staff perform a calibration (to check accuracy) test of the glucometer (device used to check blood sugar) when it malfunctioned during use for one of three sampled residents (Resident 100). This failure had the potential for licensed staff to obtain inaccurate blood sugar readings for Resident 100. Findings: During an observation on March 11, 2020, at 5:20 AM, the Licensed Vocational Nurse (LVN 5) performed a blood sugar check for resident 100, the glucometer did not give a reading. LVN 5 did not calibrate the glucometer after it malfunctioned. LVN 5 continued to check the blood sugar again without recalibration of the glucometer and it did not give a blood sugar reading. During an interview on March 11, 2020, at 6:05 AM, LVN 5 confirmed she did not recalibrate the glucometer after it malfunctioned. LVN 5 stated she never had training for use of the glucometer. During an interview on March 11, 2020, at 6:25 AM, with the LVN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the medication Remeron (a medication used to treat depression) was available for one out of six sampled residents (Resident 69) when the medication was not available for use. This failure had the potential for Resident 69 not to receive the medication as ordered by the physician. Finding: During a record review of Resident 69's Face sheet (a document with basic information about the resident), indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder (depression). During a review of Resident 69's physician order dated November 21, 2019, indicated, Remeron (a medication used to treat depression) 30 mg (milligram-a unit of measurement) tablet take one tablet by mouth every night for depression manifested by poor intake. During a review of Resident 69's medications in the back hall medication cart on March 12, 2020 at 2:47 PM with Licensed Vocational Nurse (LVN 2), the medication Remeron…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow their policy and procedure for medication administration when: 1. For Resident 8, nursing staff did not document on the Medication Administration Record (MAR-a record used to document the administration of medications) pain medication was given. 2. For Resident 4 and 33, nursing staff did not document on the MAR the amount of units of insulin (a medication used to treat high blood sugar) was given per thesliding scale (the amount of insulin given based on the blood sugar results) order from the physician. This failure resulted in inaccurate documentation of medication administration which put Residents 8, 4, and 33's health and safety at risk. Findings: 1. During a record review of Resident 8's face sheet (a document which contains basic information), indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included muscle weakness. During a review of Resident 8's physician order dated August 8, 2016, indicated, Norco…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.