Valley Vista Care Center of St Maries

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure two of two residents and their resident representatives (Resident (R) 8, and R52) reviewed for emergent hospital transfer out of a total sample of 18 residents were provided with a written bed hold policy and transfer notice. This failure had the potential to affect the resident and their resident representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include:1. Review of R8's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R8 admitted to the facility on [DATE]. Review of R8's quarterly 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of three out…

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, and facility policy, the facility failed to provide assistance with showering for two of three residents (Resident (R) 45 and R16) reviewed for activities of daily living (ADLs) out of a total sample of 18. This failure increased the potential for R45 and R16 to have unmet hygiene needs.Findings include:1. During initial rounds on 05/05/26 starting at 11:00 AM an observation of R45 revealed R45 appeared to have flaky skin, and her hair appears greasy and in need of a wash.During an interview on 05/05/26 at 1:50 PM, Family Member (F) 1 stated, R45 was not getting showers. F1 stated R45 was supposed to get three showers/baths per week but she's lucky to get one. F1 stated staff were not getting R45 dressed in the mornings. F1 presented a calendar to writer that the family was documenting showers R45 received. F1 stated that R45 only received four showers total for the month of April.Review of R45's admission Record, located in the electronic medical record (EMR)…

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, staff interviews, and policy review, the facility failed to discard expired medications stored in one medication room storage refrigerator of one medication room. This deficient practice resulted in outdated medications remaining available for use. Findings include:Observation of the medication storage room refrigerator with the Minimum Data Set Coordinator (MDSC) on 05/07/26 at 11:35 AM revealed the following medications were expired. -One Lispro Insulin 100 units/milliliter (ml) vial had an expiration date of 01/23/26. There was no open date on the vial. -One Lantus Insulin 100 units/ml vial had an expiration date of 01/23/26. There was no open date on the vial. -One Apidra Solostar Insulin 100 units/ml injection pen had an expiration date of 02/04/26. -Trulicity (medication used to manage blood sugar levels) 3 milligrams (mg)/0.5 ml injection pen had an expiration date of 01/16/26 (Two injection pens left in the carton of four). There was no open date on the medication carton. -Gabapentin (anticonvulsant medication for seizures and pain) 250 mg/5ml solution…

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 facility document review and staff interview, it was determined the facility failed to ensure they employed an RN as the full-time DNS. The failure to have a full-time RN/DNS placed residents at risk of inadequate care and supervision of their medical status for a census of 44 residents. Findings include: The facility's job description for the Director of Nursing Services, approved by the Administrator on 3/9/20, documented Responsible for the management of the nursing services in the long-term care facility and directs nursing activities . The essential duties and responsibilities included the following: The DNS has knowledge of the state and federal regulations in the delivery of resident care, is informed of residents' conditions, determines the facility capacity for the care of potential new admissions, maintains the Quality Assurance program, ensures medications, treatments and plans of care are provided to the residents, evaluates nursing care by making daily rounds of the facility, and ensures adequate staff are available for resident care. During an interview on…

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, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 44 of 44 residents residing in the facility who consumed food prepared by the facility at risk of adverse health outcomes, including food-born illnesses. Findings include: 1. The facility's Food Storage policy, undated, stated once products were opened, a use by date label must be added. This policy was not followed. On 11/27/23 at 4:00 PM, during a kitchen inspection, 7 of 18 seasoning containers appeared cloudy and moist. 7 of the 18 opened seasoning containers did not have a use by date on the container. On 11/27/23 at 4:09 PM, The Dietary Manager stated the opened seasoning containers should have a use by date, and they did not. 2. The facility's Preventing Foodborne Illness policy, revised November 2022, stated hair caps and beard restraints were worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, and utensils.…

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 document review, it was determined the facility's administration failed to ensure a full-time DNS was on staff. This failure had the potential to affect the care of the 44 residents in the facility and the assistance and care needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings include: During an interview on 11/29/23 at 10:10 AM, the Administrator stated there was no full-time RN designated to be the DNS working full-time at the facility and involved in resident care. The Administrator admitted knowledge of the need for a full-time DNS. The personnel file of the Interim DNS did not include a signed form of her job description. During an interview on 12/01/23 at 11:00 AM, the Interim DNS stated she was not in the facility on a full-time basis and had other job duties on the facility campus. The Interim DNS also stated she was not involved in resident care planning and in the provision of nursing services in the facility on a daily basis.

Based on staff interview and document review, it was determined the facility failed to report accurate Payroll Based Journal (PBJ) information for the facility as required for a census of 44 residents. Findings include: The facility's PBJ report, for 7/1/23 through 9/30/23, documented a full time RN functioned as the DNS in the facility. During an interview on 11/29/23 at 10:10 AM, the Administrator confirmed the facility did not employ a full time RN to serve as the DNS, as reported in the PBJ report. During an interview on 11/30/23 at 10:55 AM, the facility's Corporate Human Resources Representative confirmed the facility replaced the previous DNS with the Interim DNS on 5/8/23. Additionally, she confirmed the Interim DNS's employee file did not include an accepted and signed DNS job description defining job duties. During an interview on 12/1/23 at 11:00 AM, the Interim DNS stated she was not in the facility on a full-time basis and had other job duties on the facility campus, specifically in the assisted living facility, which was in another building. The Interim DNS also stated…

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 record review, policy review, and staff interview, it was determined the facility failed to ensure employees were trained on abuse. This was true for 43 of 79 employees whose records were reviewed for abuse training. This failure had the potential to place all residents in the facility for unidentified or continued abuse if an employee was unable to identify and report abuse. Findings include: The facility's Reducing the Threat of Abuse and Neglect policy, revised December 2022, stated the facility would implement and maintain an effective training program on abuse prohibition. This policy was not followed. During a review of employee abuse training, it was identified 43 of 79 employees did not complete training for abuse and neglect. On 12/1/23 at 10:32 AM, the Resident Care Coordinator stated 43 of 79 employees did not complete training for abuse and neglect.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the State Agency's Long Term Care Reporting Portal, record review, incident reports, and staff interview, it was determined the facility failed to ensure allegations of resident abuse were reported to the State Survey Agency within 2 to 24 hours. This affected 2 of 5 residents (#7 and #8) who were reviewed for abuse, and for additional unidentified residents referenced in 2 incident reports. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's policy, Reducing the Threat of Abuse and Neglect, revised 12/21/23, stated allegations of abuse were to be reported to the State Survey Agency Long Term Care reporting Portal within 2-24 hours of the event, and report the results of an investigation within 5 working days from the date of the incident. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including dementia with agitation, depression,…

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 record review and staff interview, it was determined the facility failed to ensure a resident's representative and physician were immediately notified when the resident had a significant change in condition. This was true for 1 of 1 resident (Resident #352) reviewed for notification of change in condition. This deficient practice placed Resident #352 at risk for lack of advocacy and support from their representative, and deterioration of her health status. Findings include: The facility's Change in a Resident's Condition or Status policy, revised February 2021, stated the facility will promptly notify the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition. This policy was not followed. Resident #352 was readmitted to the facility on [DATE], with multiple diagnoses including dementia with behavioral disturbances. A nurse's note, dated 1/15/22 at 4:32 AM, documented Resident #352 was repeatedly yelling help me and having visual…

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 record review, policy review, and resident staff interview, it was determined the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was completed when the resident had a clinical diagnosis of Post-Traumatic Stress Disorder (PTSD). This was true for 1 of 1 resident (Resident #16) whose PASRR record was reviewed. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to a lack of updated screening. Findings include: The Medicaid (government entity that provides health coverage to Americans) long term care PASRR website accessed on 12/14/23, documented the following: PASRR is a federal requirement for Medicaid-certified nursing facilities to help ensure that individuals are not inappropriately placed in nursing homes for long term care. The PASRR procedures include: - Evaluate all applicants for serious mental illness (SMI) and intellectual disability (ID). - Offer all applicants the most…

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, record review, policy review and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 1 of 23 residents (Resident # 26) whose care plans were reviewed. This deficiency placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents ' needs changed. Findings include: The facility's Care Plan policy, revised March 2022, documented the comprehensive, person-centered care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's Change in a Resident's Condition or Status policy, revised February 2021, documented the interdisciplinary team reviewed and updateded the care plan when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident…

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 resident and staff interview, record review, and facility policy review, it was determined the facility failed to assess, monitor, and identify potential triggers for 1 of 1 resident (Resident #16) reviewed for trauma-informed care. This failure created the potential for . Findings include: The facility's policy Trauma-Informed and Culturally Competent Care Level III, revised 8/2022, stated the purpose of the policy was to guide staff in providing care that was culturally competent and trauma-informed in accordance with professional standards of practice, and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy further defined Trauma results from an event, series of events, or set of circumstances that was experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. The policy defined…

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 policy review, observation, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when providing wound care. This was true for 1 of 1 resident (Resident #2) observed during wound care. This failure put Resident #2 at risk for infection due to cross contamination and potential exposure to bacteria and other pathogens. Findings include: The facility's Dressings, Dry/Clean policy, revised September 2013, documented after a soiled dressing was removed, to pull the soiled glove used over the dressing and discard. If gauze was used to clean the wound, use clean gauze for each cleansing stroke. The policy stated staff were to initial the clean dressing and label it with the date and time the dressing was changed. This policy was not followed. Resident #2 was admitted [DATE], with multiple diagnoses including an open wound of the abdominal wall. On 11/28/23 at 12:09 PM, LPN #1 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.