Valley View Manor Hcc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure treatments were used per standards of practice and only applied with a corresponding physician order for 2 of 2 residents (R5, R7) reviewed for non-pressure related skin concerns. Findings include:Findings includeR5's face sheet dated 11/19/25, identified diagnoses of neoplasm(cancer) of the ovary and thyroid gland, morbid obesity (excessive body fat), and abdominal hernia (where abdominal organs push through a weak spot in the abdominal wall). R5's impaired skin integrity focus care plan dated 10/31/25, identified R5 was at risk for impaired skin integrity related to morbid obesity and lack of mobility with goal of skin will remain intact. Interventions included as followed: encourage resident to frequently shift weight; encourage use of lifting devices while in bed and evaluate for pitting edema. R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 was received hospice services, was dependent with bed mobility,…

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 document review the facility failed to comprehensively assess and monitor an open blister and discoloration of skin on 1 of 1 resident (R5) and in addition failed to comprehensively assess and monitor a laceration for 1 of 1 resident (R7) reviewed for non-pressure skin issues. Findings include: R5's face sheet dated 11/19/25, identified diagnoses of neoplasm(cancer) of the ovary and thyroid gland and morbid obesity (excessive body fat).R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 dependent with bed mobility and transfers, no pressure, venous or arterial ulcers, received hospice services, and was cognitively intact.R5's clinical admission assessment dated [DATE], identified R5's skin was warm, dry, and intact. R5 had an old intravenous site on her right antecubital space (the bend in arm) and the dorsum (top) of the right hand. No other skin issues noted on the clinical admission assessment. R5's hospice note dated 10/29/25, identified R5 was admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess and monitor a pressure wound, failed to timely notify the physician of new ulcer development, and failed to provide physician ordered treatments for 1 of 1 resident (R6) reviewed for skin integrity.Findings include:R6's face sheet dated 11/19/25, identified diagnoses of hemiplegia (paralysis) affecting left side, diabetes mellitus (body does not make enough insulin), and heart failure (a condition where the heart does not pump enough blood to the body). R6's skin integrity focus care plan last revised on 4/29/25, identified R6 had a potential impairment to skin integrity related to bowel and bladder incontinence and impaired mobility. Goal to maintain or develop clean and intact skin. Interventions were as followed: may apply barrier cream after each incontinent episode; elevate heels off the bed; keep skin clean and dry, use lotion on dry skin, prefers to not be checked every two hours; pressure relieving/reducing…

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 interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 2 of 3 residents (R1, R4) who were noted to have missing information in their record. Findings include: R1's face sheet dated 11/13/25, identified diagnoses of atherosclerotic heart disease (plaque buildup in the arteries), morbid obesity (excess fat), depression (a mood disorder characterized by persistent sadness), and anxiety (a mental and physical state characterized by feelings of dread or worry).R1's Minimum Data Set (MDS) dated [DATE], was independent with transfers and was cognitively intact.During an interview on 11/14/25 at 2:04 p.m., health information manager (HIM) stated R1 had been seen for routine nursing home visits on 8/1/25 and 10/7/25, however, R1's physician visit dictated notes had not been placed in R1's electronic health record (EHR), due to the notes being located in the outside medical systems. HIM stated she does not have access to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review the facility failed to ensure there was a communication process between the long-term care (LTC) facility and the hospice provider to ensure the needs of the resident are addressed and met 24 hours per day. In addition, the facility failed to ensure a designated interdisciplinary team member (IDT) was responsible for the coordinating with hospice representative and LTC staff in the hospice care planning process for 2 of 2 residents (R2, R5) reviewed for hospice services.Findings include:Findings include:R2's face sheet dated 11/14/25, identified diagnoses of Alzheimer's disease( a progressive neurological disorder and the most common cause of dementia), congestive heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs), diabetes mellitus (the body does not produce enough insulin), and chronic obstructive respiratory failure (when the airways that carry air to the lungs become narrow or damaged). R2's Annual Minimum Data…

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 determine whether a resident was safe to self-monitor diabetic medication treatment results (blood glucose levels) for 1 of 1 residents (R13) who had a continuous blood glucose monitoring system (FreeStyle 3 Libre). Findings include: Observation and interview on 5/14/25 at 8:15 a.m., with R13 identified she had a sensor on the back of her arm and a hand held meter. She placed the meter near the sensor and it recorded her blood glucose level. She identified the nurse would come in and ask her what her blood sugar is and she would tell them. If my blood sugar is low they give me orange juice or a snack. R13 was not aware of any time that she would need to do a manual blood sugar check and was not familiar with how the alarms worked on the device. Review of R13's Self Administration of Medications assessment did not identify R13 had been given any guidance or assessed to ensure she was knowledgeable on how to use the monitor or when she would need 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 document review, the facility failed to ensure staff were competent to use a continuous glucose monitoring device (FreeStyle Libre 3) for 1 of 1 resident (R)13 who had a diagnosis of diabetes. Findings include: R13's admission Minimum Data Set (MDS) assessment identified her cognition was intact, she required assistance from staff to complete activities of daily living (ADL)'s, and had diagnosis of diabetes, heart failure, respiratory failure, bi-polar disorder, borderline personality disorder, and depression. R13's May 2025, administration record identified she was to have her blood glucose level monitored and recorded three times a day before meals. R13 was to be administered 40 units of insulin aspart protamine and insulin aspart (a combination of fast acting and intermediate acting insulin to keep blood sugar levels under control) subcutaneous two times a day at 8:00 a.m., and 4:00 p.m. In addition, R13 was to be administered a correction dose based on her blood sugar levels at the time of administration. R13's 4/30/25 through 5/13/25,…

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 dietary staff had appropriate training with competencies to carry out the function of monitoring the dish machine temperatures to ensure appropriate sanitation occurred. Findings include: Observation and interview on 5/13/25 at 9:30 a.m., with dietary aide (DA)-A who ran a load of dishes through the dish machine. The gauge located on the right side was at 170 degrees and did not move. The gauge, located on the left side moved during the wash and rinse cycle showing the wash cycle was to be 160 degrees and the rinse cycle was 180 degrees. DA-A reported she observed and documented temperatures once a shift. She reported the left gauge was the wash cycle, and the right gauge was the rinse cycle. When DA-A was asked if the temperature needed to reach a certain temperature, she replied there was no special temperature it had to be. Interview and observation on 5/13/25 at 10:11 a.m., with maintenance director identified one gauge read both the wash and rinse temperature. The maintenance director accompanied…

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 document review the facility failed to develop and implement 1 of 1 facility assessment to ensure staff were trained and deemed competent for blood glucose monitoring and device usage. In addition, the facility failed to ensure 1 of 1 dietary aides (DA-A) was trained to ensure appropriate sanitation occurred in the dishwashing machine. Findings include: BLOOD GLUCOSE MONITORING Observation and interview on 5/14/25 at 8:15 a.m., with R13 identified she had a sensor on the back of her arm and a hand held meter. She placed the meter near the sensor and it recorded her blood glucose level. She identified the nurse would come in and ask her what her blood sugar is and she would tell them. If my blood sugar is low they give me orange juice or a snack. R13 was not aware of any time that she would need to do a manual blood sugar check and was not familiar with how the alarms worked on the device. Review of R13's Self Administration of Medications assessment did not identify R13 had been given any…

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 the facility failed to ensure psychotropic medications had identified target behaviors or symptoms, failed to monitor the target behaviors or symptom, and failed to monitor for adverse effects of the medication for 1 of 4 residents (R4) reviewed for psychotropic medication use. Additionally, the facility failed to have non-pharmacological meaningful interventions that were personalized for target behaviors or symptoms. Findings include: R4's 4/24/25, quarterly Minimum Data Set (MDS) identified R4's cognition was moderately impaired. She had functional limitations of both upper and lower extremities and required extensive to total assistance with cares. R4 took an antipsychotic and antidepressant medication. The MDS identified diagnoses of neurological condition, left side weakness, heart failure, diabetes mellitus, and seizure disorder. R4's 5/13/25, Order Summary Report identified bupropion HCI ER (Wellbutrin XL) 300 milligrams (mg) every day (QD) an antidepressant medication for mood disorder due to known physiological condition. Quetiapine…

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, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 12 sampled residents (R24). Findings include: R24's 5/17/24, Preadmission Screening Results (PAS) identified no level II assessment was needed. The PAS identified that R24 had post-traumatic stress disorder (PTSD), anxiety, and depression. R24's 5/27/24, admission Minimum Data Set (MDS) assessment lacked identification of PTSD. R24's 8/27/24, quarterly and the 10/21/24, significant change MDS identified PTSD diagnosis. R24's 5/14/25, medical diagnosis list identified PTSD, depression, and anxiety. Interview on 5/14/25 at 3:52 p.m., with assistant director of nursing (ADON) identified she would expect the MDS would be coded correctly to reflect the resident's actual condition. She reported R24's admission MDS had been completed by a contracted staff and she now had taken over completing the MDS's at the facility. She confirmed that R24's admission MDS had lacked identification of the PTSD diagnosis. Which would trigger care…

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 develop and implement a comprehensive person-centered care plan that addressed anticoagulant (prevents and breaks down blood clots) therapy with safety precautions for 1 of 1 (R25) resident reviewed for care plan. Findings include: R25's 3/06/25, Significant change Minimum Data Set (MDS) identified R25 was admitted [DATE]. R25 had a diagnosis of atrial fibrillation (irregular heart rhythm) and hip fracture. R25 was moderately cognitively impaired and had taken anticoagulants on a routine basis. R25's current, undated Order Summary Report identified R25 was to receive Eliquis (anticoagulant used to prevent blood clots) 2.5 milligrams (mg) twice a day for atrial fibrillation. The order identified the medication was to start on 8/19/24. R25's current, undated care plan lacked individualized documentation of pharmacological and non-pharmacological interventions for R25, as well as, side effects and/or adverse effects of the medication use. 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, interview, and document review the facility failed to revise 1 of 1 resident (R8) care plan following a change of condition. Findings include: R8's 4/23/25, quarterly Minimum Data Set (MDS) assessment identified R8's cognition was intact. R8 required extensive assistance by one staff for transfers, toileting, and bed mobility. R8 took insulin daily and a diuretic (medication to remove fluid excess from the body). R8's 5/14/25, diagnosis list identified Alzheimer's disease, congestive heart failure, pain in right toes, pain in left ankle and foot, osteoarthritis, and diabetes mellitus. R8's 4/30/25, emergency department (ED) provider note identified R8 had presented to the ED for evaluation of increased weakness and falls. Assessment noted bruising with some swelling and tenderness of the left lower leg and ankle area. Some bruising was noted as being present on the right lower leg but without any tenderness. X-ray of left ankle revealed a fractured ankle and the ankle was splinted. The note indicated R8 would benefit from orthopedic follow-up to discuss whether…

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 document review, the facility failed to have an integrated care plan to coordinate and delineate what services hospice was to provide and what services the facility was to provide, to ensure oversight and services would be provided for 1 of 1 resident (R11) reviewed for hospice care. Findings include: R11's 3/9/25, annual Minimum Data Set (MDS) assessment identified R11 was dependent on staff for all cares, he received hospice services. R11's undated facility care plan identified activities of daily living (ADL) deficit related to dementia and muscle/skeletal impairment. R11 was dependent on staff for care needs. The nutrition focus area identified R11 had nutritional problem related to diagnosis of alcohol dependency, anxiety, hepatitis C, dementia, epilepsy, hypertension, insomnia, depression, seizures, psychosis, and hospice status. There was no other mention of hospice as a whole, nor was there mention of what services the facility was to provide, or what services hospice was to provide mentioned on R11's care plan. R11's direct care staff…

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, the facility failed to ensure 1 of 5 staff (housekeeping aide (HK)-A) was appropriately given a second tuberculosis test within 1-2 weeks after the first step was completed upon hire. Review of the current, undated Regulations for Tuberculosis Control in Minnesota Health Care Settings, located at https://www.health.state.mn.us/diseases/tb/rules/tbregsmanual.pdf for Tuberculosis Control in Minnesota Health Care Settings, identified baseline TB screening is required for all healthcare workers (HCW). Baseline TB screening consists of three components: 1. Assessing for current symptoms of active TB disease, 2. Assessing TB history, and 3. Testing for the presence of infection with Mycobacterium tuberculosis by administering either a two-step TST or single IGRA.before hire. The second TST may be performed after the health care worker (HCW) starts working with patients. An employee may begin working with patients after a negative TB symptom screen (i.e., no symptoms of active TB disease) and a negative IGRA or TST (i.e., first step) dated within 90…

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, the facility failed to complete a review of antibiotic therapy between 48-72 hours to ensure appropriateness of the continued use of an antibiotic for 1 of 3 (R21) sampled residents. Findings include: Review of the current, undated, Centers for Disease Control (CDC): The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, located at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf, identified facilities should evaluate the clinical signs and symptoms when a resident is first suspected of having an infection. Once the resident is placed on an antibiotic, they should be comprehensively reviewed within 48-72 hours after starting the medication to ensure they have been prescribed an effective medication. This is accomplished by reviewing the resident current symptoms and any laboratory results to identify medication effectiveness. The CDC identifies this process as an antibiotic time-out. Review of the infection…

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 document review, the facility failed to ensure 1 of 5 (R28) were offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC). Findings include: R28's 2/09/25, admission Minimum Data Set identified R28 was [AGE] years old and had a diagnoses of dementia, anxiety and diabetes. R28 was offered but decline the pneumococcal vaccine (PCV). R28's current, undated immunization report indicated R28 had received PCV-7 on 2/16/11, PPV23 on 6/14/13, followed by PCV-13 on 7/12/19. Review of the current, 10/26/24, Centers for Disease Control (CDC): Pneumocococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV21) at any age…

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 comprehensively assess and provide an adequate plan for supervision and appropriate interventions to protect, respect and promote rights of the resident to meet individual needs, for 1 of 3 residents (R1) reviewed for elopement. Additionally, the facility failed to ensure 1 of 1 (R1) resident care plans were revised and staff were aware of interventions to maintain resident safety. Findings include: R1's admission Minimum Data Set, dated [DATE], identified intact cognition with no behaviors. R1 was independent with toileting and oral hygiene, eating, transfers, and ambulation. R1 required supervision with shower/bath, upper and lower dressing, and personal hygiene. R1 was continent of bowel and bladder. R1's diagnoses included: coronary artery disease (CAD), atrial fibrillation (AFIB), benign prostatic hyperplasia (BPH) (enlarged prostate causes obstructive urinary flow), and obstructive uropathy. R1 required no wander guard or alarms. R1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to immediately report an allegation of abuse to the administrator and State Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of abuse. Findings include: A Nursing Home Incident Report submitted to the State Agency on 6/18/24 at 6:12 p.m., indicated R1 reported an allegation of abuse to licensed practical nurse (LPN)-A on 6/17/24 at 2130 (9:30 p.m.). R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and no noted behaviors. R1 required staff supervision with transferring, dressing, and walking, but was independent with bed mobility. R1's Progress Note subtitled Behavior Charting dated 6/17/24 at 20:38 (10:38 p.m.), indicated R1 reported that the night prior (6/16/24), a large lady turned mean and grabbed her neck and pulled her very hard which caused her neck to hurt. R1 indicated she was afraid the woman would come back to hurt her again. R1 gave a description of the woman to the LPN-A. The progress note…

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 document review the facility failed to implement enhanced barrier precautions (EBP) and ensure personal protective equipment (PPE) was used according to EBP indications for high-contact resident care activities for 2 of 2 residents (R5 and R18) with a wound and indwelling catheter. Additionally, the facility failed to monitor, track and trend for signs and symptoms of infections in the facility. Findings include: EBP R5's 4/19/24, significant change Minimum Data Set (MDS) assessment identified R5's cognition was intact, R5 required assistance of one staff for cares and transfers. R5 had an indwelling catheter and was continent of bowel. R5 had pain and took a scheduled pain medication, she was short of breath when lying flat, and had a stage 4 pressure ulcer with full thickness tissue loss that was present upon admission. R5 received pressure ulcer cares and had pressure relieving devices on her bed and in her wheelchair. R5 received daily diabetic injection, took an antidepressant, diuretic, antiplatelet, and antibiotic during the assessment…

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 the facility failed to ensure the acting infection preventionist (IP) (who is the facility's director of nursing (DON)) had completed specialized training in infection prevention and control. This had the potential to affect all 21 residents residing in the facility. Findings include: Interview on 6/04/24 at 02:16 p.m., with director of nursing (DON) stated, she had not completed her IP training and certification and planned to complete it when time allotted her to do so. She stated no other staff in the facility had IP training and she was assigned as the IP designee when the assistant director of nursing ADON resigned from his position abruptly. Interview on 6/04/24 at 02:27 p.m., with administrator stated the facility does not have a certified IP at the facility due to the ADON leaving their position at the facility and could not provide records for 2 of the residents to confirm COVID vaccines were offered. Review of 7/20/23 Facility Assessment identified the facility had a certified IP in the facility and would have monthly infection…

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 and interview the facility failed to ensure privacy of resident's medical information for 1 of 1 facility medication cart which involved 10 of 21 residents (R1, R4, R5, R6, R7, R8, R10, R11, R18, and R175). This had the potential to be viewed by any resident and visitor passing by common room across from the nursing station. Findings include: R1's, 4/13/24 quarterly, Minimum Data Assessment (MDS) identified R1 was admitted on [DATE]. R1 had a diagnosis of medically complex conditions, such as diabetes, depression, and schizophrenia. R4's, 4/03/24, Significant Change MDS identified R4 was admitted in March 2023. R4 had a diagnosis of other neurological conditions, high blood pressure, and peripheral vascular disease (PVD) (decreased blood-flow to extremities). R5's, 4/19/24, Significant Change MDS identified R5 was admitted in March 2024. R5 had a diagnoses of diabetes, depression, and respiratory failure. R6's, 5/08/24 quarterly, MDS identified R6 was admitted in June 2020. R6 had 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 document review, the facility failed to ensure 4 of 5 sampled residents (R172, R173, R174 and R175) were appropriately vaccinated against pneumonia upon admission. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE 65 years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb)…

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, the facility failed to offer the Coronavirus (COVID-19) vaccine to 2 of 5 residents (R172 and R173) reviewed for COVID immunizations upon admission. Findings include: R172's, 5/28/24 admission minimum data assessment (MDS) identified R172 was cognitively intact and had a diagnosis of anemia. R172's current, undated vaccine history log identified she had no record of being offered or declination of the COVID-19 vaccine. R173's, 5/29/24 admission minimum data assessment (MDS) identified R173 was cognitively intact and had a diagnosis of heart disease and high blood pressure. R173's current, undated vaccine history log identified he had no record of being offered or declination of the COVID-19 vaccine. Interview on 6/04/24 at 1:57 p.m., with director of nursing (DON) stated she was unsure if the facility had administered COVID vaccines to residents. She thought perhaps R172 and R173 were not interested in receiving the COVID vaccine but could not provide a declination form for either resident to show they had been instructed on risks to benefits…

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 document review, the facility failed to ensure appropriate infection control technique during 1 of 1 meal service. This had the potential to affect all 23 residents in the facility. Findings include: Observation on 3/29/24 beginning at 11:50 a.m. and extending through the noon meal service identified multiple incidents of potential cross contamination and issues with hand hygiene. Cook-A applied gloves and arranged serving utensils on top of the covered steam table pans. He then picked up tray cards from a table behind the steam table, found the card he was looking for, placed it onto a tray, picked up a plate and using a spatula in his right hand and his left gloved hand, picked up a piece of fish from the steam tray, placed it onto the plate, folded back the foil over the scalloped potatoes, placed a scoop of potatoes onto the plate, used his right gloved hand to push some potatoes back onto the plate from the edge, retrieved a slice of bread from the open bag on the side of the steam table and placed it on top of the plate of food, picked up 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.

Based on observation, interview and document review, the facility failed to implement infection control practices in accordance with Centers for Disease Control (CDC) recommendations to prevent and/or mitigate the risk of the spread of communicable disease Influenza such as utilization of appropriate personal protective equipment (PPE), appropriate hand hygiene, preventing ill staff from working, implement active symptom screening for residents and staff, and providing staff ongoing education during outbreak. The facility's failures resulted in an Influenza A outbreak that effected 9 out out of 23 residents and had the potential to effect the remaining residents, visitors, and staff. Findings include: During entrance conference on 3/27/24, State Agency was made aware of an Influenza A outbreak in the facility. The outbreak started that began on 3/16/24, effected 9 out of 23 residents. Five residents were on isolation precautions at the start of the survey. and is continuing and affecting nine out of 23 residents. Five residents (R7, R11, R13, R14 and R15). Review of the facility'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 document review, the facility failed to ensure the facility determined the required time needed for the infection preventionist based on the facility assessment, resident census and characteristics, and during communicable disease outbreaks. Further failed to ensure the IP was afforded adequate time and resources to effectively execute infection control program activities to prevent and/or mitigate the risk of infectious spread. Findings include: SEE F812: Based on observation, interview, and document review, the facility failed to ensure appropriate infection control technique during 1 of 1 meal service. This had the potential to affect all 23 residents in the facility. SEE F880: Based on observation, interview and document review, the facility failed to implement infection control practices in accordance with Centers for Disease Control (CDC) recommendations to prevent and/or mitigate the risk of the spread of communicable disease Influenza such as utilization of appropriate personal protective equipment (PPE), appropriate hand hygiene, preventing ill staff…

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 the facility failed to ensure all staff working in the dietary department had training on use of equipment, safe temperatures to ensure food safety and sanitation processes. This had the potential to affect all 23 residents in the facility. Findings include: Entrance conference on 3/27/24 at 9:15 a.m. with the director of nursing (DON) and administrator identified the facility was having issues with staffing in the dietary department and multiple staff were assisting with meal preparation and clean up. Both the DON and administrator reported they had assisted in the dietary department. The administrator reported she had worked as a dietary aide and assisted with cleanup. The DON reported she had done dishes and assisted with the dining room. Review of the dietary schedule for March 2024 identified 1 trained medication aide (TMA)-A scheduled as PM (evening meal) cook. Review of the January, February and March 2024 dietary schedules identified TMA-A worked 3 shifts in January 2024, 8 shifts in February 2024, and 9 shifts in March 2024 as 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 interview and document review, the facility failed to ensure residents had access to their personal funds upon request for 1 of 1 resident (R5) reviewed. This had the potential to effect 14 residents who utilized a personal funds account. Findings include: During an interview on 3/28/2 at 10:19 a.m., R5 stated she was able to access her money only when administration or the business office was open. She could not access her personal funds on weekends or holidays. During an interview on 3/28/24 at 2:00p.m., licensed practical nurse (LPN)-A indicated if a resident wants funds they have to go to the administrator or the business office manager during business hours. During an interview and observation on 3/28/24 at 2:26 p.m., the administrator indicated residents do have access to their money after hours and thought there was $30.00 in the medication room in a cash box if a resident requested money. Further indicated all staff should know how to access it. The administrator requested the assistance of LPN-A to gain access to the medication room holding the cash box but had…

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 the facility failed to provide required timely notifications for 1 of 2 residents ( R4) who experienced falls. Findings include: R4's 3/17/24 Significant change Minimum Data Set (MDS) assessment identified she was on hospice services (3/7/24), her cognition was intact, and she required supervision and assistance with her Activities of Daily Living (ADLs). R4 had diagnoses of dementia, malnutrition, history of falls and urinary incontinence. R4 experienced 3 documented falls in the month March and family members expressed their concern regarding supervision and factors contributing to her falls. 1.) 3/11/24 at 1:45 p.m. R4 was found lying on the floor in her room with her walker next to her. Blood was noted on the floor and she had a large lump and a laceration on the back of her head. Additional minor injuries included skin tears on her left hand, right forearm, and ankle. R4's record indicated the family was notified. 2.) 3/20/24 at 5:00 p.m. R4 was walking in the hall with her walker and had a gait belt around her waist. An unidentified staff…

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 document review the facility failed to provide adequate and specialized rehabilitative services of occupational therapy (OT) and physical therapy (PT) therapy according to residents individualized needs based on a comprehensive assessment for 2 of 2 residents (R2 and R10) who had orders for physical therapy (PT) and occupational therapy (OT). Findings include: R2's diagnoses included bilateral osteoarthritis, sepsis, pressure wound on buttocks and weakness. R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted to the facility on [DATE], did not have cognitive impairment, did have impairment to range of motions (ROM) to one upper extremity and both lower extremities, used a walker and wheelchair. R2 was dependent with lower body dressing and putting on/off footwear, personal hygiene and sit to lying position. R2 required maximal assist with toilet hygiene, shower/bathing, rolling side to side in bed, sit to stand position, and transfers. Partial assist with upper…

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 document review the facility failed to complete comprehensively assess and provide adequate of level of supervision to prevent elopement for 1 of 1 residents (R1) who had a history of elopements and fall with fracture. Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency (SA) on 11/7/23 at 12:36 p.m., indicated R1 eloped from the facility on 11/5/23 and continues to leave facility unsupervised and without staff knowledge. Indicated R1 is at a high risk for falls and further injury due to a recent fall on 10/30/23, which resulted in R1 obtaining a fracture of the right lower leg, The report further indicated R1 was not to bear weight on the right leg and always wear a knee immobilizer but R1 refused to follow the orders. R1's face sheet indicated R1 had a guardian. R1's annual Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition and was independent with transferring and ambulating. R1 used a walker. R1 did not exhibit…

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 implement policies and procedures for ensuring the reporting of a reasonable suspicion of crime in accordance with section 1150B of the Act when they were notified of suspected criminal activity by a resident (R2) occurring in the facility. Findings include: An anonymous report submitted to the State Agency on 10/10/23 at 9:30 a.m., alleged a suspicion of a crime occurring at the facility when it was reported to facility staff that R2's personal computer contained adolescent pornography. The report also indicated the facility had a history of residents sharing pornographic material on their personal computers. Further indicated the administrator and director of nursing (DON) were aware of the suspected criminal activity but had not reported to the State Agency (SA) and law enforcement. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment. Due to the fear of retaliation from facility administration, staff…

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, the facility failed to perform a comprehensive investigation for 1 of 1 resident R182 with allegation of potential misappropriation of property (missing money) by interviewing other residents, staff, and persons of interest in connection with the incident. This had the potential to affect any resident with monies kept on their person and not locked away. Findings include: Review of the 5/10/23 report to the State Agency (SA) identified R182 reported to the assistant director of nursing (ADON) some money was missing. R182 stated in April 2023, she had a friend/landlord bring her some money. R182 reported a specific amount of $3,780.00 was in the envelope. R182 denied counting it upon receipt but thought she must have. She last checked the envelope approximately 1 week prior and reported it had not felt as thick as it once was. She then counted it and discovered the envelope contained $1600.00. When staff inquired if she had any ideas who ma have taken the money, she stated there was 1 shady looking person but refused to give a name. Local law…

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, the facility failed to report an allegation of resident-to-resident abuse immediately or no later than two (2) hours to the State Agency for 2 of 3 residents (R1 and R2). In addition, the facility failed to report an allegation of resident-to-resident sexual abuse to the State Agency (SA) for 2 of 3 residents (R1 and R3) reviewed for abuse. Findings include: R1 and R2 A Facility Reported Incident (FRI) submitted to the State Agency on 8/11/23, at 1:55 a.m., alleged R1 punched R2 in the face. The resident-to-resident altercation occurred on 8/10/23, at 9:35 p.m. During an interview on 8/17/23 at 11:35 a.m., the director of nursing (DON) stated certified nursing assistant (CNA)-A notified her of the altercation between R1 and R2 on 8/11/23, at 12:30 a.m. The DON indicated the on-duty charge nurse at the time of the altercation did not notify her of the incident which caused the vulnerable adult (VA) report to be submitted late. R1 and R3 During an interview on 8/17/23 at 12:25 p.m., registered nurse (RN-A) stated R1 was aggressive and impulsive…

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 document review, the facility failed to ensure a thorough investigation of an allegation of potential sexual abuse was completed for 1 of 3 residents (R1) reviewed for abuse. In addition, the facility failed to protect residents after an allegation of abuse occurred for 1 of 3 residents (R3) reviewed for abuse. Findings include: R1 R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment. R1 was exhibiting signs of impulsiveness, lack of safety awareness, and socially inappropriate statements. R1's diagnoses included dementia with agitation. R1's care plan initiated 6/29/23, indicated R1 was at risk for elopement related to disorientation and impaired safety awareness. Care plan was updated on 8/11/23, to reflect R1 had the potential to be physically aggressive related to history of harm to others, poor impulse control, and lack of safety awareness. R1 could become physically aggressive when interacting with others. The care plan lacked…

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.