Our Lady Of The Valley

Based on staff interview and clinical record review the facility staff failed to follow physician's orders for one of 21 residents, Resident #221. The findings included: For Resident #221, the facility staff failed to change the administration times for the medication Voltaren gel per the physician's order. Resident #221's face sheet listed diagnoses which included but not limited to dementia, anxiety, depression, psychotic disturbance, hypertension, arteriosclerotic heart disease and hypothyroidism. Resident #221's most recent MDS with an assessment reference date (ARD) of 09/26/22 assigned the resident a brief interview for mental status score of 8 out of 15 in section C, cognitive patterns. This indicates that the resident was moderately cognitively impaired. Resident #221's clinical record contained a physician's order summary for April 2022, which read in part 03/25/22 Change admin times on the Voltaren gel to 6 a, 12 noon, and 9 Per daughter request thank you. Resident #221's Treatment Administration History for April 2022 contained an entry which read in part, Order: Voltaren…

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 resident and staff interview, resident observation and clinical record review, the facility staff failed to ensure that residents maintain acceptable parameters of nutrition for one of 23 residents in the survey sample, resident # 46. For resident # 46, the facility staff failed to follow the recommendations of the Registered Dietician (RD) to obtain another weight, and then do weekly weights if an actual weight loss is confirmed Additionally, the facility staff failed to ensure that resident # 46's weight loss was addressed by the physician. Resident # 46's diagnoses list included but was not limited to, Type II diabetes mellitus, gastro esophageal reflux disease, vitamin deficiency unspecified, mild protein calorie malnutrition, and chronic kidney disease. The most recent annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/11/23 assigned resident # 46 a brief interview for mental status (BIMS) score of 14 indicating mild cognitive impairment. Under Section K, Swallowing and Nutritional Status, resident # 46 was coded as weighing 118…

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 staff interview, facility document review and record review, the facility staff failed to ensure the physician reviewed the pharmacy recommendations for one of 21 residents in the survey sample, Resident #4. The findings: The facility staff failed to ensure Resident #4's Medication Regimen Reviews (MRRs) was addressed by a medical provider. Resident #4's face sheet listed diagnoses included but were not limited to dementia, Alzheimer's disease with late onset, glaucoma, Bipolar II disorder, and traumatic subdural hemorrhage. The resident's minimum data set with an assessment reference date of 08/16/23 coded the resident a having a brief interview for mental status of 04 out of 15. Resident #4 was assessed as requiring assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #4's clinical documentation included a pharmacy review for 03/14/23. The document read to see the pharmacist's review however the review was not found in the clinical record. The director of nursing (DON) was asked about the pharmacy recommendation and on 08/25/23…

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 staff interview, clinical record review and facility document review the facility staff failed to ensure care plan meetings were held in a timely manner for one of 21 residents, Resident #221. The findings included: For Resident #221 the facility staff failed to hold care plan meetings after each minimum data set (MDS) assessment. Resident #221's face sheet listed diagnoses which included but not limited to dementia, anxiety, depression, psychotic disturbance, hypertension, arteriosclerotic heart disease and hypothyroidism. Resident #221's most recent MDS with an assessment reference date (ARD) of 09/26/22 assigned the resident a brief interview for mental status score of 8 out of 15 in section C, cognitive patterns. This indicates that the resident was moderately cognitively impaired. Resident #221's clinical record was reviewed and contained Care Plan Conference Summary forms dated 11/03/21, 01/26/22, 04/20/22, 07/20/22, 10/12/22 and 11/09/22. Resident #221's clinical record contained care plan progress notes dated 01/20/21, 02/16/21, 06/09/21 and 11/03/21. There was no…

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 staff interview, clinical record review and facility document review, facility staff failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for one of 21 residents in the survey sample, Resident # 222. The findings: For Resident #222, one facility staff member transferred the resident from the bed to a chair instead of utilizing a mechanical lift with two+ staff members as required per the resident's care plan. During the transfer, the resident sat on her right lower leg which caused discomfort. An X-ray two days after the incident was negative for fracture. A subsequent X-ray three days after the incident indicated the resident had a tibial fracture. Resident #222's diagnoses included but were not limited to multiple sclerosis, adult failure to thrive, anxiety disorder, narcolepsy (chronic sleep disorder), dysphagia and other speech disturbances, neuralgia and neuritis (inflammation and nerve pain), age-related osteoporosis, insomnia and unspecified…

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 interview and facility document review the facility staff failed to store, prepare and serve food in a safe and sanitary manner. The findings included: The facility staff failed to ensure serving pans in the facility were dry and clean and failed to date an opened package of dried pasta. During initial tour of the facility kitchen, conducted on 04/13/21 at approximately 1:45 pm, surveyor observed an opened package of macaroni noodles located on a shelf in the dry storage area. Surveyor could not locate an opened on date on the package. Surveyor asked the dining services manager if there was a date on the package and dining services manager stated that there was not, and removed the package. While continuing initial tour of the kitchen, surveyor observed a rack containing metal serving pans, nested together. Surveyor asked the dining services manager to separate the pans to allow surveyor to observe inside of pans, and when dining services manager did so, water ran from between the pans. Dining services manager stated that should not happen. Surveyor also…

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 staff interviews, clinical record reviews, and in the course of a complaint investigation, the facility staff failed to ensure that residents receive treatment and care by not following physician's orders for one (1) of 16 sampled residents (Resident #105). The findings include: Facility staff members failed to ensure Resident #105's medical provider orders, for (a) a head CT and (b) the medication Zyprexa, were implemented in a timely manner. Resident #105's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/10/21, had the resident assessed as able to make self understood and as able to under others. Resident #105's Brief Interview for Mental Status (BIMS) summary score was assessed as 13 out of 15. Resident #105 was assessed as requiring assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing. Resident #105's diagnoses included, but were not limited to: anemia, heart disease, high blood pressure, anxiety, and vision problems. Resident #105 had a head CT scan ordered on 3/5/21 but this CT scan was not completed until…

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 staff interview, the facility staff failed to safely store medications in 1 of 2 medication rooms. This medication room contained expired medications. The findings included: The facility staff failed to dispose of expired medications in medication room [ROOM NUMBER]. On 04/13/2021 at 2:30 p.m., the (DON) director of nursing accompanied the surveyor to medication room [ROOM NUMBER]. This medication room contained an unlocked plastic box. Inside this box, the surveyor observed the following expired medications. 200 ml IV bag of Ciprofloxacin expiration date 03/2021, Cefepime 2-1 gram vials expiration date 10/2020, Ivanz 1 vial expiration date 04/2020, Vancomycin 1 gram expiration date 05/2020, Vancomycin 1 gram expiration date 04/2020, Gentamicin 80 mg/2 ml 8 vials expiration date 09/2020. The box was labeled with a different pharmacy name then the one currently being used by the facility. The DON stated they would take the box to their office and call the pharmacy. On 04/14/2021 at 3:08…

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 interview, clinical record review, and facility document review, the facility staff failed to maintain an effective infection prevention and control program for 1 of 16 residents, Resident #12. The findings included: The facility staff failed to complete hand hygiene during a wound care observation. The (EHR) electronic health record included the diagnoses, adult failure to thrive, diabetes, and chronic kidney disease. Section C (cognitive patterns) of Resident #12's admission (MDS) minimum data set assessment with an (ARD) assessment reference date of 01/17/2021 included a (BIMS) brief interview for mental status summary score of 5 out of a possible 15 points. Section M (skin conditions) was coded to indicate the resident did not have any pressure ulcers or wounds to the feet. On 02/05/2021, the facility staff identified a wound to the residents left heel. The resident was seen by a wound physician and this wound was classified as an arterial wound. On 04/13/2021 at 1:42 p.m., the surveyor observed (LPN) licensed practical nurse #1 complete wound 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.

Based on observation, staff interview and facility policy review it was determined the kitchen staff failed prepare food in a clean and sanitary manner for facility residents. Findings: The facility kitchen staff failed to prepare foods in a clean and sanitary manner. The initial tour of the kitchen environment began 4/7/19 at 8:00 AM. The surveyor entered the second floor dining room. A kitchenette at the rear of the dining section contained a steam table and refrigerator. A kitchen employee was stirring the breakfast foods on the steam table. None of the foods were covered with lids or wrap of any sort. The surveyor asked to see the temperature log on the foods contained in the steam table. The employee did not understand what the surveyor was asking about. When asked if she had obtained the temperatures on the food, the kitchen employee held up her hands and shook her head. She did not understand when the surveyor asked if she had a thermometer to take the food temperatures. At this point, another staff member called down to the kitchen to find someone to take the food…

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, staff interview, and clinical record review, the facility staff failed to follow physician's orders for 1 of 19 Residents in the survey sample, Resident # 14. The findings included: The facility staff failed to ensure that Resident # 14 was wearing physician ordered TED hose. Resident # 14 was an [AGE] year-old- female who was originally admitted to the facility on [DATE], with a readmission date of 3/26/19. Diagnoses included but were not limited to, congestive heart failure, type 2 diabetes mellitus, major depressive disorder, and hyperlipidemia. The clinical record for Resident # 14 was reviewed on 4/7/19 at 2:55 pm. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 4/2/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 14 had a BIMS (brief interview for mental status) score of 10 out of 15, which indicated that Resident # 15's cognitive status…

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, staff interview, and clinical record review, facility staff failed to provide services to prevent urinary tract infections for 1 of 19 Residents in the survey sample, Resident # 52. The findings included: The facility staff failed to ensure that Resident # 52 Foley catheter was secure with a leg strap. Resident # 52 was an [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of 5/25/17. Diagnoses included but were not limited to, obstructive and reflux uropathy, type 2 diabetes mellitus, dementia with behavioral disturbance, and hypertension. The most recent MDS (minimum data set) assessment for Resident # 52 was an annual assessment with an ARD (assessment reference date) of 3/16/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 52 had a BIMS (brief interview for mental status) score of 5 out of 15, which indicated that Resident # 52's cognitive status was severely impaired.…

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 staff interview, facility staff failed to securely store medication in 1 of 2 medication rooms. On [DATE], when the surveyors arrived to the facility at 7:45 AM, the door to the medication room behind the nurse's station on [NAME] hall was open. The treatment cart was unlocked. No nursing staff were present in the room or at the nurse's station nearby. Two nurses were working medication carts in the hall and the nursing supervisor was in the dining room. The medication refrigerator was unlocked. There were no controlled substances in the refrigerator. None of the stored medications were expired. The door to the medication room was closed by 8:15 AM. The medication rooms were not observed open and unattended again during the survey. The director of nursing was notified of the concern during a discussion on [DATE] at approximately 3 PM. The director of nursing stated she would address the issue with nursing staff.