Valley View Care Center

Penalty

12 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide First Aid and CPR per standards of practice for a resident who was found on the floor in a large pool of blood and without a heartbeat. The resident had an advance directive indicating full code status and had diagnoses including end stage renal disease and essential hypertension. According to the record, the resident was found around 7:10 AM by staff after a CNA alerted an LPN that the resident was on the floor in blood. The LPN checked for signs of life, found no pulse, and did not initiate CPR. The LPN reported that she believed the resident was bleeding from the fistula site but did not assess the source of bleeding or attempt to stop it. She stated that she decided not to start CPR because there was too much blood and they would have been "sloshing around in the blood." An RN who responded also checked for a pulse, found none, and did not initiate CPR because he felt it was a biohazard due to the amount of blood loss. Neither staff member could report who called 911 or whether there was a delay in calling emergency services. EMS documentation described the resident lying supine on the floor with approximately 4 to 5 pints of blood around him, blood spatter in the room, and no pulse. EMS noted no rigor mortis or lividity and documented asystole on the cardiac monitor. The resident was pronounced dead at 7:36 AM. Interviews with the CNA, RN unit manager, DON, and NHA showed that staff believed CPR was not needed because of the blood loss, and the facility did not provide evidence that staff had assessed the bleeding source before deciding not to begin life-saving measures.

Penalty

12 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from resident-to-resident mental and verbal abuse when Resident #96 repeatedly threatened and directed profanity toward Resident #19. Resident #19 was cognitively intact with a BIMS score of 15/15 and had no documented verbal or physical behaviors toward others. Resident #96 had a history of cerebral infarction, could not complete BIMS due to cognitive limitations, had impaired memory and moderately impaired decision making, and his care plan called for anticipating needs, redirecting him as needed, minimizing overstimulation, and using brief, simple cues. During an observation, Resident #96 was assisted into his wheelchair and then heard in the hallway saying he was going to kill a staff member. He then self-propelled into Resident #19’s room, stopped near the resident’s bed, and yelled, "I'm going to kill you" and "You're dead" while using profanity. Resident #19 later reported that Resident #96 had threatened him multiple times in recent months and that he felt threatened in his own home. He stated he kept his curtain pulled around his bed and watched the reflection on his roommate’s television so he could see if Resident #96 was entering his room, and he said he feared Resident #96 might hit him. Staff interviews showed they were aware Resident #96 had been angry and fixated on believing Resident #19’s television was bothering him, but they were not aware of any interventions in place to prevent Resident #19 from being verbally abused. A CNA reported prior similar incidents in which Resident #96 yelled at Resident #19 and wanted to fight him, and another CNA stated she had witnessed Resident #96 yelling profanity at Resident #19 before. The UM reported he was not aware of any interventions to avoid Resident #96 directing anger toward other residents, and the NHA was not aware of previous altercations between the two residents. The abuse policy defined mental abuse as harassment and threats and verbal abuse as disparaging, derogatory, or offensive language toward residents.

Penalty

12 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adaptive dining equipment was provided consistently for residents who had care plans, diet orders, and assessments specifying special eating equipment and utensils. The deficiency involved Resident #62, Resident #132, and Resident #102, all of whom had severe cognitive impairment documented on mental status screening and had nutrition or hydration-related care plans that included adaptive dining items such as two-handled cups with sip lids, bent-left utensils, and a scoop plate. Resident #62 had an anoxic brain injury with left-sided spastic hemiplegia and severe cognitive impairment. During lunch observation, he was eating in the dining room with staff nearby and was independently taking fluids, but the cup containing red liquid had a concave lid with a tiny hole intended for a straw rather than a sip lid, and he was observed unable to get juice from the cup when he tilted it. Later observations showed that he had a proper double-handled cup with sip lid in his room, but at another time the adaptive cup was out of reach and the only drink within reach was a disposable foam cup without a sip lid. The RD confirmed the observed lid was not a sip lid and stated the resident should have received the adaptive equipment listed in his care plan, meal ticket, and diet order. Resident #132 had dementia, hemiplegia/hemiparesis, and dysphagia, with orders and assessments calling for a two-handled cup with sip top lid and bent-left utensils. During a meal observation, he was served beverages in double-handled cups with spout lids and water in a disposable foam cup with a lid and straw, and he was provided straight metal utensils instead of bent-left utensils. He was observed eating pureed food with his finger. Resident #102 had dementia and a care plan and physician order for a scoop plate, but during lunch he was served on a regular plate instead of a scoop plate, and food was pushed off the plate onto the tablecloth around it.

Penalty

12 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely report suspected abuse involving two residents to the State Agency within the required 2-hour timeframe. Resident #19 was cognitively intact with a BIMS score of 15/15 and no documented physical or verbal behaviors toward others on the most recent MDS. Resident #96 had a history of cerebral infarction due to embolism of the left cerebral artery, could not complete the BIMS because of cognitive limitations, had impaired short- and long-term memory, and was moderately impaired for decision making. His care plan identified severe cognitive impairment and included interventions to anticipate needs, redirect as needed, minimize overstimulation, and use brief, simple cues. During an observation, Resident #96 was heard yelling threats and profanity at CNA SS and CNA CC, then quickly self-propelled his wheelchair into Resident #19's room and shouted, "I'm going to kill you" and "You're dead" at Resident #19. CNA SS removed Resident #96 from the room and later reported the incident to the nurse and Unit Manager. The Unit Manager reported the incident to the NHA, who stated she was informed the morning of the incident, delayed interviewing Resident #19, observed that he was emotionally upset, and then reported the event to the State Agency as possible abuse. The NHA confirmed the report was not made within 2 hours as required by the facility's abuse policy.

Penalty

12 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely and consistent ADL care to Resident #117, who had diagnoses including urinary incontinence and overactive bladder and was cognitively intact with a BIMS score of 15. The resident’s care plan directed staff to boost her to a 45-degree angle at the beginning of each CNA shift, apply a protective skin barrier after each incontinence episode, and assist with frequent position changes and turning/repositioning while in bed or in a wheelchair. During observation, the resident was found lying in bed eating lunch with her upper body nearly flat because she had slouched down, and she reported being very uncomfortable and that staff told her she was already high enough when she asked to be boosted. The resident also reported that she had not yet received incontinence care that day and usually only got assistance once per shift. On another observation, she reported being wet with urine, that the last check or change had been more than 6 hours earlier, and that her bottom was getting sore; she also stated she was only rolled once every 8 hours and preferred to be woken during the day for incontinence care and repositioning every 2 hours. Staff interviews indicated the resident required 2 people for care and had not yet been seen for care that day. When CNA C later provided care, the resident’s brief was visibly saturated with urine, her buttocks were red with creases from the brief and bedding, and a small superficial open area was noted on her right inner thigh, with a small amount of BM also observed during cleansing.

Penalty

12 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Contact precautions were not effectively in place for a resident with MRSA and a recent hospital return for a foot infection. The resident had physician orders for contact precautions three times a day for MRSA, and the room had contact precaution signage and gowns hanging on the door during observations. However, gloves were not available outside the room during two observations, and a therapy staff member was observed donning a gown and then entering the room to look for gloves. The infection preventionist later confirmed that gloves had been missing earlier that day and that a cart with gowns and gloves was then placed outside the room. Standard infection control practices were not followed during care for a resident with enhanced barrier precautions for a foley catheter and chronic wounds. During incontinence care and wound care, a CNA changed gloves after care but did not perform hand hygiene before putting on clean gloves and resuming care. An RN used a double-glove technique during wound care, removed the top pair of gloves, and continued care with the inner pair already on, without performing hand hygiene at any point during the care. The RN stated the double-glove method was used so she would not have to stop and change gloves during care. Standard infection control practices were also not properly implemented during incontinence care for another resident who was incontinent of urine and reported being wet for more than 6 hours. The resident was observed with a visibly saturated brief, red buttocks, and a small superficial open area on the right inner thigh. A CNA cleaned the resident, did not change soiled gloves after contact with urine and stool, used a gloved hand to scoop cream from a container on the nightstand, and applied cream to the resident while continuing care with the same gloves. After removing the soiled gloves, the CNA did not perform hand hygiene before donning clean gloves to gather soiled linens.

Penalty

12 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #142 received ordered diabetes care, including blood glucose monitoring and insulin administration, in accordance with professional standards of practice. Resident #142 had diagnoses that included type 2 diabetes mellitus and essential hypertension. The record showed orders for blood glucose monitoring twice daily for 7 days starting 8/7/25 and insulin lispro sliding scale three times daily for diabetes, but the treatment administration record and blood sugar summary showed no documented blood glucose monitoring after 8/14/25 and no insulin administrations after 8/14/25. Resident #142’s chart also documented elevated blood glucose values, including 478.0, 307, 353, 298, and 254 in August 2025. Provider notes stated to continue Lantus and sliding scale insulin and to monitor blood sugar trends, and later notes continued to document insulin and accu-checks. Despite this, the facility did not have blood glucose monitoring or insulin orders documented after the initial monitoring order ended. The family member reported that after discharge the facility did not indicate that blood glucose monitoring and insulin were needed, and the resident became ill within two days of discharge and was hospitalized with blood glucose in the 600s. The MD later confirmed the facility had not been checking blood glucose levels and stated that this was an error.

Penalty

12 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the physician notes reflected an accurate representation of the resident’s current condition and that meaningful assessments of the resident’s condition were completed for one resident reviewed for quality of care, resulting in a lack of coordination of care and insufficient treatment for diabetes mellitus. The resident had diagnoses including type 2 diabetes mellitus and essential hypertension. After a hospital readmission in August 2025, the resident had orders for blood glucose monitoring twice daily for 7 days and insulin lispro sliding scale, but the record showed no blood glucose monitoring documented after the order ended and no insulin administration documented after that time. The blood sugar summary also showed several elevated glucose values, including 478.0, 307, 353, 298, and 254. Physician notes documented by an NP on 8/8/25 and 9/4/25 and by an MD on 10/8/25 stated that diabetes was controlled or medically controlled and that insulin and blood sugar monitoring should continue, even though the resident did not have active orders for those services after 8/14/25. During interview, the unit manager confirmed that the resident did not have blood glucose monitoring or insulin orders placed after 8/14/25. The MD stated he was not sure why the insulin had been discontinued, confirmed the August glucose values were not euglycemic, and acknowledged that he noticed the facility had not been checking blood glucose levels but did not look into it further. He also confirmed that the NP notes indicated the resident was supposed to continue blood glucose monitoring and insulin despite there being no active orders.

Penalty

Inspection fine: $14,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to adequately supervise and ensure the safety of a resident who was assessed to be at risk for elopement. The resident, who had severe cognitive impairment, dementia, and a history of exit-seeking behavior, was able to leave the premises without staff knowledge and remained missing for approximately 17 hours. Multiple staff interviews and record reviews confirmed that the resident had been displaying exit-seeking behaviors throughout the morning, including asking staff for directions to a hotel and attempting to exit through various doors. Despite these behaviors and a care plan indicating the need for interventions such as one-to-one supervision as deemed necessary, the resident was not placed on one-to-one supervision at the time of the incident. Staff reported that the resident was difficult to keep track of and was observed wandering throughout the facility, setting off door alarms, and repeatedly asking to leave. Several staff members, including CNAs, LPNs, and social services, noted the resident's confusion and persistent attempts to exit. The resident was last seen by staff in the late morning, and after a search of the facility, it was determined that he was missing. The facility's elopement assessment had previously identified the resident as being at risk, and interventions such as wander guard bracelet checks and reassurance were documented, but these measures were not sufficient to prevent the elopement. Interviews with facility leadership, including the DON and NHA, revealed that there was an expectation for staff to implement additional interventions, such as one-to-one supervision, for residents exhibiting exit-seeking behavior. However, on the day of the incident, these interventions were not implemented, and staff did not escalate the level of supervision despite clear signs of risk. The resident was ultimately found by local police and returned to the facility without significant injury, but the failure to provide adequate supervision and prevent the elopement constituted a serious deficiency.

Removal Plan

• Code 7 was paged overhead indicating missing resident.
• Staff began completing a head count and searching for missing resident inside and outside the facility.
• Administration was notified.
• Police were notified.
• All doors, alarms, and wander guard system were tested, and all functional.
• All wander guards were verified for placement and function.
• A facility wide audit of elopement risks was completed to ensure all residents at risk had been identified and had care plans in place.
• Elopement book was reviewed to ensure all residents at risk had pictures and information in place.
• Facility elopement and missing person policy were reviewed.
• All staff present in the facility were educated on the elopement policy and the missing person policy.
• A plan was put in place to educate every staff member prior to their next working shift.
• Facility confirmed all door alarms and wander guard system were operating properly and were monitored for functionality daily.
• The code to the 600 hall door was changed by the maintenance director.
• A sign was placed on the 600 hall door indicating it was not an exit, and visitors should enter and exit through the main entrance.
• Facility ensured signs were posted to educate visitors on the need to avoid assisting any residents through a door.
• Resident #100 was placed on one to one after returning to the facility until he discharged from the facility.
• Facility ensured elopement drills were conducted daily for 3 days.
• Facility ensured elopement drills were conducted weekly.
• All wander guards were verified for placement and function.
• A facility wide audit of elopement risks was completed to ensure all residents at risk had been identified.
• Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement.
• The facility elopement books were reviewed to ensure all at risk residents had pictures and information located in the books.
• The facility policy for elopement and/or exit seeking management and missing person policy were reviewed and deemed appropriate.
• All staff present in the facility were educated on policy, warning signs of elopement, how to identify an at risk resident, what to do if a resident is exit seeking, how to redirect an exit seeking resident, who to notify if a resident is exit seeking, and each staff member was given a laminated check list related to missing resident to attach to their name badge.
• Education of all staff members was completed except for staff members who were on approved leave. The staff members on leave would be educated upon their return to work.
• Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement.
• Facility confirmed all door alarms and wander guard system were operating properly and were monitored for functionality daily.
• The code to the 600 hall door was changed by the maintenance director.
• Daily door alarm checks continued.
• A sign was placed on the 600 hall door indicating it was not an exit.
• Facility ensured signs were posted to educate visitors on the need to avoid assisting any residents through a door.
• Resident #100 was placed on one to one until resident discharged from the facility.
• Facility ensured elopement drills were conducted daily for 3 days.
• Facility ensured elopement drills were conducted weekly.
• Elopement policies, procedures, educations, assessments and root cause were reviewed in QAPI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care and services that promote dignity and respect for two residents reviewed for dignity and respect. One resident, who was cognitively intact and had a diagnosis of major depressive disorder, reported experiencing call light wait times of up to 30 minutes. She stated that the delays resulted in her soiling her brief and having to wait a long time for staff to change it, which made her feel degraded. Staff interviews confirmed that this resident did not refuse care. Another resident, with moderate cognitive impairment and a diagnosis of a depressive episode, also reported long wait times for staff to change her brief, describing an incident where she felt she waited "forever" and expressing that it made her feel like an old lady. Staff, including CNAs and an LPN, acknowledged that residents sometimes complained about long call light wait times, and confirmed that this resident did not refuse care. These findings indicate that the facility did not consistently honor residents' rights to dignity and timely assistance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective Quality Assurance and Performance Improvement Program (QAPI) to address medication errors, as evidenced by two incidents involving residents receiving incorrect medications. In the first incident, a resident was administered another resident's medications, including a mix of antidepressants, antipsychotics, blood thinners, and other medications, due to a failure to verify the resident's identity. In the second incident, another resident received a different set of incorrect medications, including blood pressure and diabetes medications, again due to a failure to verify the resident's identity. The facility's QAPI records showed no documentation of identifying the deficient practice related to these medication errors, no analysis of the causes, and no corrective action plan. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that while medication errors were mentioned in QAPI meetings, there was no further analysis or preventive measures discussed. The DON later provided a timeline of the errors, indicating that the root cause was not verifying resident identity, but this was created after the incidents and not as part of the QAPI process.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to the decisions of the court-appointed co-guardians of a resident who was adjudged incompetent, leading to emotional distress for the resident. The resident, who functioned at the level of a 6-year-old child, was involved in a situation where the facility staff did not comply with the guardians' requests to limit interactions between the resident and a specific staff member, Scheduler EE. Despite the guardians' concerns about the appropriateness of the relationship and its impact on the resident's psychosocial wellbeing, the facility allowed the interactions to continue, including the exchange of notes and the use of familial terms like 'goddaughter.' The resident's guardians, FM TT and FM UU, expressed concerns about the resident's exposure to gossip and inappropriate relationships within the facility. They reported that the resident's mood had declined, and she exhibited behaviors such as breaking her cell phone and refusing to see family members. The facility's staff, including the Nursing Home Administrator and Director of Nursing, did not take steps to address the guardians' concerns, believing that the resident had the right to choose her interactions, despite her limited capacity to make such decisions. Interviews with various staff members, including the Social Work Director and Medical Director, confirmed that the resident did not have the capacity to consent to relationships and that the facility should have honored the guardians' wishes. The ongoing conflict between the facility staff and the resident's family, along with comments made in the resident's presence, contributed to the resident's frustration, confusion, and emotional distress. The facility's failure to follow the guardians' directives and protect the resident from these conflicts resulted in a deficiency in the care provided.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain professional standards of nursing practice related to medication administration, resulting in medication errors for two residents. In the first incident, a Registered Nurse (RN) prepared medications for a resident but handed them to a Licensed Practical Nurse (LPN) who then administered them to the wrong resident. The RN documented the administration in the electronic medication administration record (EMAR) as if she had administered the medications herself. Both the RN and LPN acknowledged that the nurse who prepares the medications should be the one to administer and document them, following the five rights of medication administration. In the second incident, another RN administered the wrong medications to a resident after confusing their identity with another resident who was in close proximity. Both residents used reclining wheelchairs and were in the dining room at the time. The RN admitted to being distracted by other residents' behaviors during the medication pass, which contributed to the error. The RN had been familiar with the residents in that part of the building, yet still made the mistake. The facility's policy requires that the person who prepares the medication dose is the one who administers it, and residents must be identified before medication is administered. Identification methods include checking the photograph attached to the medical record and verifying with other facility personnel if necessary. The facility's Director of Nursing (DON) expected nurses to verify the identity of residents before administering medications and to administer medications they had prepared themselves.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #2, who was cognitively intact and had diagnoses including Type 2 diabetes, hypertension, and dementia, was administered her roommate's medications. This included a mix of medications such as insulin, morphine sulfate, and other drugs not prescribed to her, leading to an altered level of consciousness, lethargy, and the need for supplemental oxygen. The error occurred when two nurses were working together to pass medications, and one nurse administered the wrong medications to Resident #2. Family members of Resident #2 reported a lack of communication from the facility regarding the incident and the resident's condition. They expressed frustration as they were not informed about the specific medications administered and had difficulty reaching staff for updates. Observations from family members indicated that Resident #2 was lethargic, hallucinating, and required oxygen, which she had not needed for months. It took over two weeks for Resident #2 to return to her usual level of coherence. Resident #9 also received another resident's medications due to a mix-up in identity by a nurse who was distracted during the medication pass. The nurse realized the error after administration and reported it immediately. The facility's policy requires that the person who prepares the medication also administers it and verifies the resident's identity before administration. However, these procedures were not followed, leading to the medication errors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement proper infection control measures for a resident with a urinary catheter and for the storage of CPAP masks for two residents. Resident #2, who had a urinary catheter, did not have enhanced barrier precautions (EBP) implemented as required. Observations revealed that staff did not wear gowns or gloves during care activities such as transferring the resident and changing bed linens. Interviews with staff confirmed that EBP should have been in place for residents with catheters, but the Infection Preventionist/Registered Nurse admitted to missing the order for EBP and only updated the care plan after the oversight was identified. Additionally, the facility did not ensure proper storage of CPAP masks for Resident #5 and Resident #6. Resident #5's CPAP mask was found on the floor and on an overbed table without a barrier, while Resident #6's mask was left uncovered on a dresser. Interviews with staff indicated a lack of consistent practice in storing CPAP masks, with some staff unaware of the proper procedures. The Director of Nursing stated that CPAP masks should be stored with a barrier when not in use, highlighting a gap between expected and actual practices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety, as observed during a survey. An open bottle of lemon juice was improperly stored on a dry storage shelf, despite the manufacturer's label indicating it should be refrigerated after opening. The contents of the bottle were found to be milky and discolored, indicating potential spoilage. Additionally, four full pans were observed stacked and stored wet on the clean pots and pans storage rack, contrary to the requirement that equipment and utensils be air-dried after cleaning and sanitizing. During meal service, a staff member was observed plating meals while wearing gloves that had been compromised by her artificial fingernails, which were roughly an inch in length. The nails had broken through the gloves, posing a contamination risk. Furthermore, utensils used for serving food were improperly stored, with handles occasionally falling into the food. Another staff member was seen discarding green beans back into the steam table after realizing a meal ticket required a different vegetable, which is against food safety protocols. These practices have the potential to result in foodborne illness among residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in long call light wait times and unmet care needs. This deficiency was observed in several residents, including those who were cognitively intact and had specific care plans that were not adhered to. For instance, one resident with Parkinson's disease was found lying in bed with wet pants and a strong odor of urine, indicating a lack of timely assistance. Despite being scheduled for showers, the resident had only received three since mid-September, and staff reported being unable to check on him due to time constraints. Another resident, who was at risk for skin breakdown and had a history of severe pressure ulcers, reported not receiving assistance to get out of bed or being repositioned as needed. This resident expressed frustration over the lack of staff availability, which hindered his ability to participate in activities or even change positions in bed. Observations confirmed that the resident had been left in the same position for extended periods, and when care was finally provided, it was evident that his incontinence needs had not been addressed in a timely manner. The report also highlighted concerns from a resident council meeting, where multiple residents reported long wait times for call lights, especially during nights and weekends. Residents expressed concerns about being told to soil themselves due to the lack of timely assistance. Additional interviews with residents and family members revealed similar issues, with reports of inadequate rounds, delayed assistance, and injuries occurring due to rushed care. Staff interviews confirmed the challenges in meeting care expectations, with some staff acknowledging the inability to respond to call lights promptly due to workload constraints.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that call lights were within reach for two residents, resulting in their inability to call for staff assistance. Resident #82, who has Parkinson's disease and is moderately cognitively impaired, was observed lying in bed with a call light pad placed approximately three feet out of reach. Due to his condition, Resident #82 was unable to reach the call light, and staff interviews confirmed that he could not use it because of his contracted arms. Despite the care plan intervention stating that the call light should be accessible, it was not within reach, leaving Resident #82 unable to request assistance. Similarly, Resident #126, who has a history of falls and is also moderately cognitively impaired, was found in her room unable to locate her call light on two separate occasions. On one occasion, the call light was at the end of her bed, and on another, it was on the floor under the bed, both times out of her reach. Resident #126 expressed her need for assistance and reported being unable to call for help due to the call light's inaccessibility. The facility's call light policy requires that call lights be placed within reach of residents, but this was not adhered to, resulting in unmet care needs for Resident #126.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accurate documentation of a resident's code status, which is a physician's order determining the type of medical treatment a person will receive if their heart or breathing stops. This deficiency was identified for one resident who was reviewed for advanced directives. The resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease, had a signed Do Not Resuscitate (DNR) order. However, the facility's records inaccurately reflected the resident's code status as CPR (cardiopulmonary resuscitation), indicating that staff would initiate CPR if the resident's heart or breathing stopped. The discrepancy was discovered during a care conference, where the social worker responsible for reviewing and ensuring the accuracy of residents' advance directives confirmed the error. The social worker was unable to explain why the resident's code status was updated to CPR, despite the resident's clear preference for a DNR order. The resident confirmed during an interview that she wished for the facility to follow the DNR order and had never indicated a desire to change her code status. This oversight resulted in the potential for the resident's end-of-life wishes not to be honored by the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately complete the Minimum Data Set (MDS) assessments for one resident, resulting in an inaccurate reflection of the resident's discharge status. Specifically, the MDS assessment for a resident with a reference date of July 26, 2024, incorrectly indicated that the resident was discharged to a short-term general hospital, whereas the admission record and progress notes confirmed that the resident was discharged to a different nursing home on the same date. This discrepancy was identified during an interview with the MDS Nurse, who acknowledged the error in the submitted MDS assessment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) Level II determination requests were sent to the Community Mental Health Services Program (CMHSP) for two residents, resulting in the potential for delayed mental health services. Resident #49, who has diagnoses including schizoaffective disorder and major depressive disorder, did not have a Level II evaluation on record since 2021. The Director of Social Services was unaware of the need for a Level II evaluation until it was discovered during an interview, and the local community mental health agency was not informed of the resident's return to the nursing home. Similarly, Resident #26, with diagnoses of bipolar disorder, anxiety, and depression, had a change in condition that warranted a Level I evaluation, but the required Level II evaluation was not completed by the due date. The resident's care plan indicated the need for specialized mental health services, but the necessary documentation and follow-up with the community mental health services were not adequately managed. This oversight in the PASARR process for both residents highlights a deficiency in ensuring timely mental health evaluations and services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the comprehensive care plan for a resident after a fall incident, resulting in an inaccurate reflection of the resident's care needs. The resident, who was admitted with a diagnosis of muscle weakness, experienced a fall when another resident accidentally activated the remote control of her electric recliner, causing her to slide to the floor. Despite the incident being documented, the care plan was not updated to include new interventions to prevent further falls. Interviews with facility staff revealed that the interdisciplinary team (IDT) did not implement any new fall interventions or update the care plan following the incident. The Clinical Care Coordinator believed the care plan had been updated to ensure the remote control was secured, but upon review, it was found that no such intervention was added. The lack of action was attributed to the resident's family insisting on hospital evaluation, which led to the resident's hospitalization for a few days.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, resulting in unmet care needs. Resident #19, who has Parkinson's disease and is cognitively intact, was observed multiple times lying in bed with a strong odor of urine and wet clothing. Despite his requests for assistance, staff did not provide timely help, and he reported not receiving a shower as scheduled. The resident's care plan indicated he required assistance with bed mobility and transfers, yet he had only received three showers over a month-long period. Resident #20, who is paraplegic and has a history of severe pressure ulcers, also did not receive necessary care. He reported difficulty getting out of bed due to insufficient staff and expressed concerns about inadequate wound care and repositioning. Observations confirmed that he had been left in the same position for extended periods, and his bedding was soiled with bodily fluids. His care plan required assistance with bed mobility and repositioning every two hours, which was not consistently provided. Interviews with staff, including a CNA and the Clinical Care Coordinator, revealed that both residents required regular assistance with ADLs and repositioning. However, due to staffing issues, these needs were not met, leading to prolonged periods without care and potential health risks. The facility's failure to adhere to the residents' care plans and provide necessary assistance contributed to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement necessary interventions to prevent skin breakdown for a resident at risk for pressure ulcers. The resident, who was admitted with diagnoses including paraplegia, myasthenia gravis, and osteomyelitis, was assessed to be at moderate risk for pressure ulcers. Despite having a care plan that included interventions such as repositioning and floating heels, the resident reported not receiving proper wound care or repositioning. The resident expressed concerns about being left in the same position for extended periods and not receiving timely care, which contributed to the deterioration of existing wounds. Observations and interviews revealed that the resident had been left in a soiled state, with a foul odor present and multiple open, weeping areas on the lower buttocks and upper thighs. The care staff acknowledged the resident's need for repositioning every two hours due to a history of Stage 4 pressure ulcers and moisture-associated skin damage (MASD). However, the resident's care was delayed, and the incontinence brief and pad were found saturated, indicating inadequate attention to the resident's needs. The clinical care coordinator expressed concern over the odor and drainage, highlighting the facility's failure to adhere to the care plan and provide necessary interventions to prevent further skin breakdown.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement proper infection control practices, as evidenced by multiple observations of inadequate hand hygiene and unsanitary conditions of resident equipment. An LPN was observed exiting a resident room without using hand sanitizer, despite the facility's policy of 'wash in/wash out' which requires hand hygiene before and after entering rooms and handling medications. The LPN continued to handle the medication cart and laptop without sanitizing her hands, even after acknowledging the oversight. Additionally, a CNA reported that sanitizing wipes were not always available for shared equipment, contributing to the lack of proper disinfection. Observations also revealed that resident wheelchairs and shared equipment, such as sit-to-stand lifts, were not maintained in a clean condition. Two residents were noted to have dirt and debris on their wheelchairs, and shared equipment like the sit-to-stand lift and hoyer lift were found soiled with dust, debris, and food crumbs. Staff interviews confirmed that these items were not being cleaned between uses, contrary to the facility's policy and CDC recommendations. This lack of adherence to infection control protocols created unsanitary conditions and increased the risk of cross-contamination and disease transmission among residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to uphold the dignity of two residents, resulting in potential negative psychosocial outcomes. Resident #60, who had a history of falls related to COPD, hypertension, and peripheral vascular disease, reported that staff took a long time to assist him when he needed to use the restroom, leading to him soiling himself. Despite the facility's call light system designed to alert staff to residents' needs, Resident #60 experienced delays in receiving assistance, which upset him as he was capable of using the bathroom but required help due to his broken foot/ankle and ongoing IV antibiotic treatment. Resident #71, diagnosed with cerebral palsy, depression, legal blindness, and moderate intellectual disabilities, was subjected to a distressing incident involving LPN Q. The LPN, in what he described as a thoughtless joke, falsely informed Resident #71 that her sister had died, causing her significant emotional distress. Despite LPN Q's immediate retraction and apology, Resident #71 was visibly upset and cried, as confirmed by her family member and the Director of Nursing. The incident was exacerbated by the resident's history of trauma and mood alterations related to depression, which were documented in her care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a comprehensive, person-centered care plan for a resident with a diagnosis of stage 4 pressure ulcers. The resident was admitted with specific care needs, including the use of soft heel offloading boots to prevent further pressure ulcers. However, observations on multiple occasions revealed that the resident was not wearing the prescribed soft boots, nor were they found in or around the resident's room. This indicates a lack of adherence to the care plan designed to address the resident's pressure ulcer prevention needs. Further investigation revealed that the physician's orders explicitly required the application of PRAFO boots when the resident was in and out of bed. Despite this, during a wound dressing change, the registered nurse was unable to locate the soft boots and was unsure of their whereabouts. This lack of implementation of the care plan and physician's orders resulted in an incomplete reflection of the resident's care and monitoring needs for pressure ulcer prevention.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure comprehensive and accurate documentation of medical records for two residents, resulting in an inaccurate reflection of their medical treatments. For Resident #17, there were multiple instances of missing documentation regarding wound care treatments, including cleansing and dressing changes for the right heel, sacral wound, and left shin. The Clinical Care Coordinator (CCC) responsible for reviewing nursing staff documentation was unaware of these omissions and had not followed up with the staff responsible for the missing entries. For Resident #43, there was no documentation of care tasks completed by CNAs during the night shift over several days. The CCCs were responsible for monitoring the electronic health record (EHR) for outstanding documentation but were unable to explain the lack of entries for Resident #43's toileting status and other care tasks. It was revealed that the CNA responsible for Resident #43 during these shifts did not have access to the EHR system due to an expired password, which prevented her from documenting the care provided. Interviews with facility staff, including the CCCs and the scheduler, confirmed that there was a lack of awareness and communication regarding the CNA's inability to access the EHR. The facility's policy required licensed staff to document care provided in the medical record, but this was not adhered to, leading to incomplete records for the residents involved.