Spring Valley Health And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R)(R5) reviewed.R5 had a fall; the facility did not initiate immediate intervention to prevent future falls, complete staff education and review and revise care plan fall interventions.This is evidenced by:Facility policy titled, Accidents/Falls - HDGR, with a review date of 12/2024, states in part: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Procedure: 5. Resident care plans should be evaluated and updated with each fall with a new and applicable intervention based on root cause. The focus is to be on prevention and…

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 did not ensure 2 of 2 residents (R) with an NG-Tube (Nasogastric) in the facility received the appropriate treatment and services to prevent complications of enteral feedings and medication administration. (R7 and R19)R19 had unlabeled/dated enteral solutions being administered.R19 and R7's Gastrostomy tube (G-tube/ feeding tube) placement was not appropriately assessed prior to medication administration. Example 1Per provided facility policy, titled Care and Treatment of Feeding Tubes, dated copyright 2024 The Compliance Store, LLC, states: Policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with intervention to prevent complications to the extent possible.The American Society for Parenteral and Enteral Nutrition, Enteral Nutrition Practice Recommendations (2017, Journal of Parenteral and Enteral Nutrition-Vol 41, Number 1, Jan/February 2017, 34-44) indicate that a label…

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 did not ensure 1 (R1) of 1 resident reviewed for post-traumatic stress disorder (PTSD) received culturally competent, trauma informed care in accordance with professional standards of practice and accounting of resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of R1.R1 does not have a person-centered care plan for triggers and interventions for R1's PTSD diagnosis. Findings:The facility policy titled Trauma Informed Care dated 12/2025 documents: This community ensures that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident . Person-centered care plan will be developed with resident's and /or family involvement to attain or maintain the highest practicable…

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 did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility did not ensure that food that was opened was thrown out according to policy. The facility did not cover food as it was being distributed in the hallways. The facility did not ensure staff used proper hand hygiene when distributing food and that hair nets were in place. This has the ability to affect all 33 of 33 residents residing in the facility. Findings include: Example 1 Expired/undated food The facility policy entitled, Food Storage, dated year 2021 states, 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days of discarded as per the 2017 Federal Food Code. On 07/30/24 at 8:30 AM, Surveyor performed initial tour of kitchen where they noted items in the refrigerator that were leftovers having open…

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 did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 33 residents in the facility. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to effect 33 of 33 residents reviewed. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 and Norovirus during an outbreak. -Observations were made of the facility not implementing Enhanced Barrier Precautions (EBP) for 2 of 3 sampled residents (R187, R186) on EBP. -Certified Nurse Assistants (CNA) were observed not wiping down Hoyer lifts after leaving an EBP…

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 did not ensure prescription medications were administered by qualified staff. Surveyor observed Certified Nursing Assistant (CNA) apply prescribed Nystatin powder to a resident's (R) skin for 1 of 1 observation. (R187) Findings include: On 07/30/24 at 8:56 AM, Surveyor observed Nystatin powder sitting on bedside table in R187's room. Surveyor asked R187 what the powder was on the bedside table and if it was stored in R187's room regularly. R187 indicated that it is antifungal powder for R187's abdominal folds. R187 indicated that the CNAs usually apply this when CNAs get R187 out of bed. On 07/30/24 at 10:01 AM, Surveyor observed morning cares being performed for R187 by CNA H and CNA Q. Surveyor observed a cup of Nystatin powder located on R187's bedside table. CNA Q picked up the Nystatin powder and handed the powder to CNA H. CNA H applied Nystatin powder to R187's abdominal folds bilaterally and placed Nystatin powder in R187's groin area. On 07/31/24 at 11:16 AM, Surveyor interviewed CNA H and asked what 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 observations, interviews and record reviews, the facility did not provide spinal precautions and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 18 residents (R21) reviewed. Staff did not follow spinal precautions to manage R21's T11 fracture by not providing log rolling during repositioning while R21 was in bed. Staff did not follow physician orders to keep back brace on R21 when head of bed is over 30 degrees. Findings include: R21 was admitted on [DATE]. R21's diagnoses include fracture of T9-T10 vertebra, fracture of first lumbar vertebrae, fracture of second lumbar vertebrae, fracture of third lumbar vertebrae, fracture of fourth lumbar vertebrae, concussion without loss of consciousness, and traumatic brain injury. R21's Minimum Data Set (MDS) assessment, completed on 07/17/24, confirmed R21 scored 12 during a Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R21 requires total…

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 did not ensure that 2 of 4 residents (R) reviewed for pressure injuries (PI) (R2 and R187) received care consistent with professional standards of practice to promote healing of existing PIs. R2 developed an unspecified injury stage PI to the left heel on 05/30/23 and an ulcer to the great right toe. On 07/09/24, the PI reoccurred to the left heel and the right great toe. On 07/09/24, a new PI occurred to the left great toe. The care plan for PI interventions was not updated since 08/14/23. R2 was not repositioned or encouraged as needed for pressure relief as instructed on the PI care plan. R187 was admitted to the facility with a stage 3 PI to the left posterior thigh. The facility did not ensure R187's buttocks/thighs were protected, did not reposition R187, and inconsistent assessments of the wounds were noted. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points,…

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 did not ensure acceptable parameters of nutritional status to maintain usual body weight. This occurred for 1 of 1 resident reviewed for nutritional status. Resident (R) R21. R21 was not weighed weekly to assess if she was maintaining her usual body weight. R21 had significant weight loss that were not assessed appropriately. This is evidenced by: R21 was admitted on [DATE]. R21's diagnoses include fracture of T9-T10 vertebra, fracture of first lumbar vertebrae, fracture of second lumbar vertebrae, fracture of third lumbar vertebrae, fracture of fourth lumbar vertebrae, concussion without loss of consciousness, and traumatic brain injury. R21's Minimum Data Set (MDS) assessment, completed on 07/17/24, confirmed R21 scored 12 during a Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R21 requires total substantial maximal assistance with rolling from side to side. R21 does not get out of bed. R21's care plan included the following…

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 did not ensure 2 of 5 residents (R16, R31) were free from unnecessary medications. R16 and R31 were prescribed lorazepam as needed (PRN), beyond the 14-day limit, without a documented rationale. Findings include: R16 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and heart failure, anxiety disorder, and schizophrenia. R16's most recent MDS assessment completed on 04/10/24 confirmed R16 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. On 07/31/24, Surveyor reviewed R16's physician orders which included lorazepam Oral Tablet 0.5 MG, give 0.5 mg by mouth every 4 hours as needed for anxiety until end date 10/03/2024. The start date was 04/04/2024 for the lorazepam. On 07/31/24, Surveyor reviewed R16's medication administration record (MAR), and noted PRN lorazepam was administered in June and was administered twice (06/01/24, 06/02/24). On 07/31/24, Surveyor…

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 staff interviews, the facility did not ensure Certified Nursing Assistant (CNA) received a performance review every 12 months for four of four CNAs reviewed. (CNA H, CNA M, CNA N, CNA O). The facility failed to have a system in place to ensure that performance reviews were being done for any of the facility CNAs. This had the potential to affect all 38 residents resided in the facility. This is evidenced by: On 04/25/24, a random sample of CNAs employed by the facility were selected for review for the completion of annual performance reviews. The facility provided the following information: CNA H has been employed at the facility since 11/16/20. An annual performance review could not be located. CNA M has been employed at the facility since 09/04/21. An annual performance review could not be located. CNA N has been employed at the facility since 02/13/23. An annual performance review could not be located. CNA O has been employed at the facility since 09/04/21. An annual performance review could not be located. On 04/25/24 at 11:00 a.m., Surveyor…

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 and record reviews, the facility did not conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility did not review and update that assessment, as necessary, and at least annually. The lack of assessment has the potential to affect all 38 residents. Findings include: On 04/25/24, Surveyor reviewed the document titled Facility Assessment Summary and Report, dated August 2017, with a review date of February 2022 and a review date of March 2023, as the facility's assessment. Page 1 of the assessment states that in August 2017, a consulting service assessed the facility. The intent for this initial facility assessment is to be reviewed on an annual basis, with updates to be incorporated as indicated and as appropriate. The assessment refers to statistics that are not current in 2024, such as: This assessment shows census trends for the facility from 2014-2022. The assessment states that some experts predict that as many as 20-30%…

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 did not ensure mandatory staffing data submitted from FY (Fiscal Year) Quarter 4, 2023 (July 1-September 30) to FY Quarter 1, 2024 (October 1-December 31) was complete, accurate, and auditable. This has the ability to affect the census of 38. This is evidenced by: The Payroll-Based Journal (PBJ) Staffing Data Reports generated quarterly document the facility triggered for Failed to have Licensed Nursing Coverage 24 Hours/Day from July 1, 2023, to December 31, 2023, for specified dates. The specified dates are as follows: FY Quarter 4, 2023: 07/16, 08/05, 08/13/, 08/19, and 09/24. FY Quarter 1, 2024: 10/22, 10/31, 12/04, 12/25, and 12/31. The facility did not produce the data that was submitted during this time frame for the specified dates therefore the Surveyor was not able to audit the exact document(s) that were submitted. Surveyor reviewed the facility's timecard sheets for each date that was specified in the report and all dates had licensed nursing coverage 24 hours per day. Surveyor reviewed the facility's Daily Schedule…

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 record review, the facility did not implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of sexual abuse was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and law enforcement where state law provides for jurisdiction in long-term care facilities) in accordance with state law for 2 of 2 abuse allegations reviewed for Resident (R1). On 03/28/24, a Certified Nursing Assistant (CNA) found R2 in R1's room. R2 was shirtless, zipping and buttoning R2's pants while in R1's bed. R1 stood in the middle of the room with a T-shirt and no pants. Allegation not reported to State Agency or Law Enforcement. On 04/01/24, a CNA found R2 in R1's room. R1 was in bed on R1's back. R2 was lying with R2's head next to R1's feet, R2's feet on the floor with R2's legs off 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 interviews and record review, the facility did not ensure that 1 of 1 resident (R) alleged violations of abuse were not thoroughly investigated (R1). On 03/28/24, a Certified Nursing Assistant (CNA) found R2 in R1's room. R2 was shirtless, zipping and buttoning R2's pants while in R1's bed. R1 stood in the middle of the room with a T-shirt and no pants. The facility did not investigate this incident. On 04/01/24, a CNA found R2 in R1's room. R1 was in bed on R1's back. R2 was lying with R2's head next to R1's feet, R2's feet on the floor with R2's legs off the bed and pants and brief pulled all the way down to R2's feet with bare buttocks on the bed next to R1's waist, and R2's penis was exposed. The facility did not conduct a thorough investigation. Findings include: The facility policy titled Abuse, Neglect, and Exploitation dated April 2008, with the current revision date of January 2023, states: The residents have a right to establish a relationship with another individual, which may include 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 record review and interviews, the facility did not ensure 2 out of 5 Certified Nursing Assistants (CNA), (CNA H, CNA N), employed at the facility for more than one year received a minimum of 12 hours of in-service training each year. This has the potential to affect all 38 residents in the facility. This is evidenced by: On 04/25/24, Surveyor requested in-service training hours for CNA H and CNA N for review. CNA H's date of hire is 11/16/20, and the facility did not provide 12 hours of in-service training, which included communication, behavioral health, and dementia care. CNA N's date of hire is 02/13/23, and the facility did not provide 12 hours of in-service training, including communication, behavioral health, and dementia care. Surveyor was unable to total yearly training hours for CNA H and CNA N due to the documents provided being unreadable. Surveyor continued requesting Director of Nursing (DON) B to provide total hours of training and topics three times during the survey; the facility continued to provide unreadable documents. This lack of clarity hindered the…

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

Based on observations, interview and policy review, the facility did not store food under sanitary conditions. This has the potential to affect 27 of 31 residents. Chicken salad in the refrigerator was not discarded on or before the expiration date. This is evidenced by: On 06/19/23 at 9:50 AM, Surveyor observed chicken salad dated 05/29/23 in refrigerator number 2. Note on refrigerator states that food must be thrown out after 5 days. Interview with [NAME] N stated that the chicken salad should have been thrown out by 06/02/23. [NAME] N immediately threw it out. [NAME] M stated that food is good for 5-7 days. On 06/20/23 at 8:31 AM, Surveyor interviewed Dietary Manager (DM) O. DM O stated that the dates on containers are when the food was made or opened. He was told of the 21 days the chicken salad was in the refrigerator and that the regulation is to discard on or before the expiration date. DM O stated that he has a note on the fridge that the foods are only good for 5 days and he will remind the staff again but has done this several times. When asked for the policy and procedure…

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 did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Housekeeping staff was observed cleaning public restroom and then going directly to clean resident rooms and going from one resident room to another without changing gloves or performing hand hygiene. This had the potential to affect all residents in the facility. Certified Nursing Assistant (CNA) observed leaving resident (R9) room multiple times to obtain supplies from supply closet without removing Personal Protective Equipment (PPE). The resident was on Enhanced Barrier Precautions (EBP) due to wounds. This had the potential to affect all residents on the Springs Household. Medication Tech (MT) touched a pill with bare hands prior to administering it to R27. RN did not sanitize the scissor for dressing change on 1 of 1 residents observed for…

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 interviews, the facility did not implement their abuse policy in regard to screening for 1 of 2 employees that resided out of state. Out of state background check was not completed for [NAME] M. Findings include: The facility policy, entitled Preventing Violations of Residents Rights and Resident Abuse with an initiated date of 12/19/17 reads in part, A good faith effort to obtain out-of-state conviction records from any state or other U.S. jurisdiction will be made for any Applicants in which Spring Valley Health and Rehabilitation Center, Inc. has knowledge of that Applicant having resided in another state or jurisdiction within the 3 previous years from time of application for employment. On 06/20/23, Surveyor requested Caregiver and Criminal background checks for a sample of 8 employees. On 06/21/23, the employee background information was reviewed. Cook M was hired on 11/20/22. The Background Information Disclosure form indicated that [NAME] M had lived in Minnesota. Surveyor requested the background checks for Minnesota from the Director of Nursing…

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 did not develop and implement a comprehensive care plan for 1 of 12 residents reviewed (R3). R3 did not have a care plan for a chronic condition of Pyogenic arthritis. This is evidenced by: R3 was admitted to the facility on [DATE] and has a diagnosis of pyogenic arthritis in left artificial knee joint. This is a chronic bacterial infection requiring prophylactic antibiotic treatment. On 06/20/23 at 2:12 PM, Surveyor reviewed R3's physician orders. Physician orders show that R3 is prescribed Doxycycline Hyclate Oral Tablet 100 MG Give by mouth two times a day for preventative therapy with start date of 04/24/23. On 06/20/23 at 2:30 PM, Surveyor reviewed R3's comprehensive care plan. R3 did not have a care plan for pyogenic arthritis with prophylactic antibiotic treatment. On 06/21/23 at 10:30 AM, Surveyor requested a care plan for R3's pyogenic knee from DON B. At approximately 10:45 AM, DON B stated to Surveyor that R3's care plan for pyogenic knee was in…

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 did not review and revise the comprehensive care plans for 2 of 12 sampled residents (R). (R9 and R15) R9's care plan was not updated to identify new open wounds on legs and interventions were not revised to show current treatment for open wounds. R15's care plan was not updated to identify the current plan for resident keeping smoking materials in room and leaving the facility grounds to smoke independently. Findings include: R9 was admitted to the facility on [DATE] and had diagnoses including in part, pulmonary embolism, open wound left lower leg, local skin infection, morbid obesity, chronic kidney disease, mild cognitive impairment of unknown etiology, and non-pressure chronic ulcer of lower leg. R9's Minimum Data Set (MDS) assessment, dated 04/19/23, indicated R9 had open lesions other than ulcers, rashes or cuts and moisture associated skin damage (MASD). On 06/19/23 at 1:44 PM, Surveyor observed R9 seated in the dining room. R9 had a dress…

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 did not ensure a resident was transferred safely with hoyer (sling) lift to prevent accidents for 1 of 2 residents (R) observed transferred by mechanical lift. (R2) Surveyor observed R2 transferred from bed to chair with a hoyer lift with only one staff person assisting the transfer. Findings include: R2 was admitted to the facility on [DATE] with the following diagnoses in part, stage 3 pressure ulcer of sacral region, paraplegia, unspecified thoracic spinal cord injury at unspecified level. On 06/20/23 at 9:31 AM, Surveyor observed Certified Nursing Assistant (CNA) D assist R2 transfer from bed to wheelchair using a hoyer lift. CNA D assisted R2 reposition in bed and placed the lift sling under the resident. CNA D attached the sling straps to the lift. CNA D began raising the lift to raise R2 off the bed. Surveyor stopped CNA D and asked if they needed to get a second staff member to assist with the transfer. CNA D stated it was okay to transfer…

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 observations, interviews and record review, the facility did not ensure that a resident who is fed by enteral means received the appropriate treatment to prevent complications of enteral feeding in 1 resident (R) (R33), of 1 resident observed for cares with a Gastric tube (G-tube). R33 receives enteral feeding by G-tube. Facility staff did not follow the current standard of practice to check G-tube placement prior to administration of enteral feeding. Findings include: The American Association of Critical Care Nurses, April 2016, Initial and Ongoing Verification of Feeding Tube Placement in Adults advises, .Checking Tube Location at Regular Intervals After Feedings Are Started, Unfortunately, feeding tubes can become dislocated during use. For this reason, it is necessary to monitor tube location at regular intervals while the tube is being used for feedings or medication administration. Observing for change in external tube length .Reviewing routine chest and abdominal radiography reports .Observing…

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 and interview, the facility did not ensure residents received insulin safely to meet their needs. Staff administered Lantus insulin to a resident (R) from a vial that was three days beyond the discard date for 1 of 1 insulin injections observed. (R3) Findings include: According to the Food and Drug Administration (FDA), insulin vials should be discarded 28 days after opening the vial to ensure effectiveness of the medication. On 06/20/23 at 8:10 AM, Surveyor observed Med Tech (MT) C draw up 10 units of Lantus insulin in a syringe for R3. MT C verified the vial with the correct resident name, correct medication, and correct dose. MT C brought the insulin syringe to Registered Nurse (RN) L to verify correct dose was drawn up in the syringe. MT C administered the insulin injection to R3. On 06/20/23 at 9:48 AM, Surveyor interviewed MT C about procedure for drawing up and administering insulin. Surveyor asked to see R3's Lantus insulin vial. MT C retrieved the insulin vial from R3's medication cupboard and noted that the vial was marked date opened 05/20/23. 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.