Springs Valley Meadows

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 3 residents observed for incontinence care and 3 of 7 residents observed for medication pass. The nursing staff failed to change gloves after touching multiple items in the room before starting incontinence care, touched medications with bare hands, and a washed hands with a five second lather. (Resident 61, Resident 21, Resident 24, Resident 45, Registered Nurse 32, CNA 14, CNA 21, CNA 44)Findings include: 1. On 4/27/26 at 6:35 A.M., Registered Nurse (RN) 32 was observed prepping medications for Resident 21. She pulled the card of medications up from the cart, put the following medications into her bare hand, placed them into a medication cup, and administered them to the resident: one Aspirin 81 milligrams (mg) tablet for anticoagulation one Lisinopril 5 mg tablet for high blood pressure one memantine 10 mg tablet for dementia one Zoloft 50 mg tablet for depression one Vascepa 1 gram (gm) tablet for high cholesterol one Vitamin D3 25 microgram (mcg)…

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 narcotics were double locked in the medication cart for 1 of 2 medication carts observed. Narcotic box on medication cart was not locked. (South Long Hall Medication Cart)Finding includes:On 4/27/26 at 6:15 A.M., the South Long Hall Medication Cart narcotic box was observed to be unlocked.During an interview on 4/30/26 at 9:09 A.M., Licensed Practical Nurse (LPN) 56 indicated medication carts should always be locked, and the narcotic box should always be under a double lock.On 5/2/26 at 10:25 A.M., a current Controlled Substances Policy, dated November 2024, was provided by the Administrator and indicated, . It is the policy of this facility that all controlled substances will be stored . by state regulations . All controlled substances administered by the facility should be kept under double lock . 410 Indiana Administrative Code (IAC) 16.2-3.1-25(n)

Based on observation, interview, and record review, the facility failed to accurately document in clinical records for 1 of 1 resident reviewed for hospice, and 1 of 3 residents reviewed for nutrition. A resident's clinical record contained a different resident's hospice records and snacks were documented as eaten when not consumed. (Resident 6, Resident 11)Findings include: 1. On 4/28/26 at 10:36 A.M., Resident 6's clinical record was reviewed. The diagnosis included, but was not limited to, Alzheimer's disease. The most recent significant change MDS (Minimum Data Set) assessment, dated 3/13/26, indicated hospice care.Resident documents included, but were not limited to, scanned and uploaded hospice documentation dated 4/7/26. The documentation belonged to a different resident in the facility that was also under hospice care.On 4/29/26 at 10:35 A.M., the Director of Nursing (DON) indicated hospice documentation was generally uploaded to the resident's clinical record every three months, with updates to the plan of care, and when the resident passed.2. On 4/28/26 at 10:41 A.M.,…

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 maintain safe and secure storage of medications for 1 of 4 medication carts observed. The narcotic box lid inside the cart was not closed completely to engage the lock. (South Long Hall Medication Cart) Finding includes: On 2/26/25 at 9:45 A.M., the South Long Hall Medication Cart was observed. The lid was not closed completely to engage the lock. Narcotics were observed stored in the box at the time. At that time, Licensed Practical Nurse (LPN) 24 indicated it was not broken and should have been closed and locked. During an interview, on 2/26/25 at 1:44 P.M., the Director of Nursing (DON) indicated all narcotics should be double locked. On 2/26/25 at 2:36 P.M., a current Medication Storage Policy, revised 6/30/23, was provided by the DON and indicated . The community should store Schedule II-V controlled substances [narcotics] and other medications deemed by the community as at-risk for abuse or diversion in a separately locked, affixed compartment in a cart . 3.1-25(n)

Based on observation, interview, and record review, the facility failed to provide meals at an acceptable temperature for 1 of 1 lunch trays sampled on 1 of 2 units. Food was served cold. (South Hall) Finding includes: During an interview on 2/24/25 at 11:33 A.M., an anonymous resident indicated the food was not served hot. During an interview on 2/26/25 at 1:35 P.M., an anonymous resident indicated the food was not served hot. During an observation on 2/26/25 at 11:46 A.M., the South Hall meal trays were being distributed to resident rooms from a meal cart. The individual meals were covered with an insulated dome with a base. At 11:52 A.M., a hall tray was sampled. The cheeseburger temperature was 113 degrees Fahrenheit. It was cold to the touch and tasted cold, and the cheese was not melted on the hamburger. During an interview on 2/26/25 at 2:11 P.M., [NAME] 25 indicated cheeseburgers should be a minimum of 145 degrees Fahrenheit when they are served to the residents. On 2/26/25 at 1:21 P.M., a current Food Temperatures policy, revised 6/2023, was provided by the Administrator…

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 interview, the facility failed to ensure person centered interventions were implemented for dementia related behaviors for 1 of 5 residents reviewed for dementia care. (Resident 5) Findings include: The record for Resident 5 was reviewed on 3/20/24 at 6:35 a.m. The diagnoses included, but were not limited to, dementia with agitation, cognitive communication deficit, and insomnia. The physician's order, dated 5/12/22, indicated the resident may receive psychiatric services. The physician's order, dated 5/17/22, indicated staff were to apply a wanderguard to the resident's right wrist for exit seeking behavior, and to check the device for function daily. The resident was to be monitored for exit seeking behavior every shift. The Activity Assessment, dated 5/18/22, indicated the resident was interviewed by the Activities Director on her activity preferences. She documented the following were somewhat important: -Having coloring books, word searches, and puzzle books. -Listening to gospel…

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 and interview, the facility failed to ensure Social Services followed up on residents that exhibited mood and behavior issues, and failure to consult with family members related to behaviors for 4 of 6 residents reviewed for Social Services. (Residents 8, 33, and 54) Findings include, 1. The record for Resident 8 was reviewed on 3/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, vascular dementia with mood disturbance, disorder of adult personality and behavior, and seizures. The Quarterly MDS (Minimal Data Set) assessment, dated 2/13/24, indicated the resident was moderately cognitively impaired. The nurse's note, dated 6/20/23 at 9:13 a.m., indicated the resident told the nurse of his wife's passing. The resident was encouraged to talk about his concerns or feelings. The nurse was able to sit and talk with the resident. The nurse's note, dated 6/20/23 at 11:42 p.m., indicated the resident came back at the beginning of the shift. The resident was tearful at times due to his wife's passing. The resident wanted to go to bed early. The nurse's…

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, record review, and interview, the facility failed to ensure accurate documentation of controlled substances on the controlled drug record sheet for 2 of 27 residents reviewed for narcotic storage. (Residents 2 and 28) Findings include: 1. During an observation of the South Short Hall Medication Cart on 3/18/24 at 10:17 a.m., with QMA (Qualified Medication Aide) 3 Resident 2's acetaminophen-codeine number (#)4 medication card contained only 20 tablets of the medication. Resident 2's clonazepam 0.5 mg (milligrams) medication card contained only 22 tablets of the medication. The controlled drug storage record sheet indicated there should be 21 doses of the acetaminophen-codeine #4 and 23 tablets of the clonazepam 0.5 mg remaining. The last doses signed out on the controlled drug storage record sheet were on 3/17/24 at 5:00 p.m. The record for Resident 2 was reviewed on 3/18/24 at 10:20 a.m. The diagnoses included, but were not limited to, generalized anxiety disorder and muscle spasm. The physician's order, dated 11/19/20, indicated the resident received…

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, record review, and interview, the facility failed to ensure medication errors less than 5% for 3 of 30 medication observations of medication administration. (Resident 28) Findings include: During an observation of medication administration for Resident 28 on 3/18/24 at 10:32 a.m., QMA (Qualified Medication Aide) 4 indicated she was preparing medications for Resident 28. She obtained one tablet of Ativan 0.5 mg (milligram) from the narcotic drawer and placed it into a medication cup. She then obtained two tablets of potassium 10 meq (milliequivalent) and 1 tablet of levothyroxine 150 mcg (micrograms) from the medication cart and dispensed them into the same cup. She did not have the Resident's MAR (Medication Administration Record) pulled up on her computer. She then pulled up a copy of the resident's physicians order, and prepared the rest of the resident's morning medications, which included coreg 6.25 mg, clopidogrel 75 mg, gingko biloba, hydrochlorothiazide (HCTZ) 12.5 mg, imdur 20 mg three one half tablets to equal 30 mg, lisinopril 10 mg, Namenda 10 mg,…

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, and interview, the facility failed to ensure appropriate labeling and storage of medications for 3 of 27 residents reviewed for Medication Storage. (Residents 33, 61, and 273) Findings include: 1. During an observation of the South Short Hall Medication Cart on [DATE] at 10:17 a.m., with QMA (Qualified Medication Aide) 3, there was a bottle of lispro, dated [DATE], with Resident 33's first and last name written on it in black marker. The bottle was open and approximately three-quarters full. There was also a Fiasp insulin pen for Resident 33, dated [DATE]. The record for Resident 33 was reviewed on [DATE] at 1:00 p.m. The diagnosis included, but was not limited to, type 2 diabetes mellitus. The physician's order, dated [DATE], indicated the resident received Fiasp FlexTouch U-100 insulin pen per sliding scale four times daily. The order was discontinued on [DATE]. The physician's order, dated [DATE], indicated the resident received insulin lispro U-100 per sliding scale four…

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 and interview, the facility failed to promptly obtain dental services for 1 of 2 residents reviewed for dental services. (Resident 23) Findings include, The record for Resident 23 was reviewed on 3/19/24 at 10:34 a.m. The diagnoses included, but were not limited to, functional dyspepsia, constipation, muscle weakness, chronic vascular disorders of the intestine, nausea, and vomiting. The admission MDS (Minimal Data Set) assessment, dated 2/6/24, indicated the resident was moderately cognitively impaired. The care plan, dated 3/4/24, indicated the resident had some of his natural teeth lost. He did not have dentures or a partial plate. The interventions included, but were not limited to, obtaining dental consult as indicated, and observing chewing or eating difficulties at meals. The nurse's note, dated 7/29/23 at 9:50 a.m., indicated the resident continued to complain of oral pain due to the loss of a filling. Slight redness was observed on the gum. Resident 23 stated, it makes it difficult to chew Staff would continue to monitor the resident. The nurse's…

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 ensure an accurate account of controlled medications dispensing and administration records were maintained. Medication administration records were not completed and/or did not match controlled substance records and controlled substance records were dated incorrectly. (Resident B, Resident C, Resident D, Resident F, Resident G, Resident H) Findings include: 1. During a review of facility reported incidents on 1/31/2 at 12:50 P.M., an incident, dated 10/9/23, included that during an audit, a concern for inaccurate documentation of PRN (as needed) narcotic administration. Medication administration date was noted to be prior to received date. During record review on 1/31/24 at 11:40 A.M., Resident B's physician orders included, but were not limited to hydrocodone-acetaminophen 5-325 mg (milligram) as needed (started on admission date 10/4/23). Resident B's medication administration record indicated the first date the resident received a PRN hydrocodone-acetaminophen 5-325 mg medication was on 10/7/23. A review of Resident B's…

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 ensure residents were free from verbal abuse for 1 of 1 allegations of abuse. A staff member cursed at a resident while the resident was exhibiting inappropriate behaviors. (Resident D) Finding includes: During a review of facility reported incidents on 1/31/2 at 12:45 P.M., an incident, dated 10/25/23, included that a staff member used inappropriate language while having a conversation with Resident D. During record review on 1/31/24 at 1:30 P.M., Resident D's diagnoses included but was not limited to dementia, recurrent depressive episodes, major depressive disorder, and altered mental status. Resident D's most recent Annual MDS (Minimum Data Set) Assessment, dated 11/2/23, included that the resident was cognitively intact. Resident D's care plan included but was not limited to resident exhibits bothersome behavior towards others. An approach included educate resident on the reason it is not appropriate to bother others (started 3/2/22). Resident exhibits sexual inappropriate comments toward female staff. An approach…

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.