| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** | |
| F 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Reasonably accommodate the needs and preferences of each resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) the resident on 4/11/19 from the hospital. Record review of the resident’s care plan, dated 4/11/19, showed the following: -Resident has an activities of daily living (ADL – dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to [MEDICAL CONDITION] (paralysis of one side of the body) and stroke diagnoses; -Ensure the resident’s call light is within reach and encourage the resident to use the call bell to call for assistance; -Resident has a communication problem related to [MEDICAL CONDITION] (an impairment of language, affecting the production or comprehension of speech and the ability to read or write); -Staff to anticipate and meet needs; -Resident is able to nod head yes or no. Record review of the resident’s fall scale, dated 4/11/19, showed the resident is a high fall risk. Record review of the resident’s admission nurse note dated 4/12/19, at 9:11 A.M., showed the following: -Late entry for 4/11/19 at 11:40 P.M.; -Resident arrived from the hospital; -admission orders [REDACTED] -Resident is non-verbal, but is able to follow conversation and make needs known by nodding or shaking head. Record review of the resident’s admission minimum data set (MDS – a federally mandated comprehensive assessment tool), dated 4/18/19, showed the following: -Severe cognitive impairment; -Disorganized thinking, behavior present, fluctuates (comes and goes); -Required extensive assistance of two or more staff with bed mobility; -Required extensive assistance of one staff with transfers, dressing, eating, toileting, and personal hygiene; -Total dependence on staff for bathing assistance; -Functional limitation in range of motion, upper extremity and lower extremity impairment on one side; -[DIAGNOSES REDACTED]. -Receives physical therapy (PT), occupational therapy (OT), and speech therapy (ST), five times per week each. Observation on 4/24/19, at 3:15 P.M., showed the resident lay on the bed in his/her room, and the resident’s call light lay in the middle of the room on the resident’s floor, out of the resident’s reach. Observation on 4/26/19, at 10:50 A.M., showed the resident lay on the bed in his/her room, and the resident’s call light lay in the middle of the room on the resident’s floor, out of the resident’s reach. Observation on 4/30/19, at 12:40 P.M., showed the following: -The resident lay on the bed, he/she asked surveyor for assistance in getting out of bed for lunch; -The resident’s call light lay across a table located approximately 18 inches away from the resident’s bed on the resident’s immobile right side, out of reach of the resident’s left hand. Observation on 5/02/19, at 12:15 P.M., showed the following: -The resident alone in his/her room, laying on the bed with the tray table across the bed with a lunch plate on the tray; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) -The resident’s drinks were out of his/her reach. -The resident’s call light was connected to the bed frame below the level of the mattress on the right side, out of the resident’s sight and reach. During an interview on 5/07/19, at 11:05 P.M., the Director of Nursing (DON) said all staff should ensure the resident’s call light is in the resident’s reach before leaving the resident’s room. MO 938 | |
| F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) -Original admission date of [DATE]; -[DIAGNOSES REDACTED]. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath). Record review of the resident’s care plan, dated 12/21/18, showed the following: -Resident has activities of daily living self-care deficit as evidenced by need for extensive assist at times related to disease process, [MEDICAL CONDITION]; -Resident will receive assistance necessary to meet ADL needs; -Assist to bath/shower as needed. Daughter-in-law to give shower due to his refusal to allow staff to give shower; -Assist with daily hygiene, grooming, dressing, oral care, and eating as needed; -The focus, goal, and interventions were initiated on 11/16/17. Record review of the resident’s quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Supervision with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Total dependence with bathing, one person assist. Record review of the resident’s (MONTH) 2019 shower sheets showed the following information: -Resident received a shower/bed bath on 02/06/19, 02/13/19, 02/20/19, and 02/27/19. Record review of the resident’s (MONTH) 2019 shower sheets for (MONTH) 2019 showed the following: -Resident received a shower/bed bath on 03/06/19, 03/13/19, and 03/28/19. Record review of the resident’s (MONTH) 2019 shower sheets for (MONTH) 2019 showed the following: -Resident received a shower/bed bath on 04/10/19; -Resident refused a shower on 04/13/19; -Not applicable was marked on 04/12/19, 04/18/19, 04/19/19, 04/20/19, and 04/25/19. Record review of the resident’s shower sheets from 05/01/19 to 05/03/19, did not show any showers/bed baths complete. During an interview on 04/29/19, at 3:15 P.M., the resident’s responsible party (RP) said the resident is not receiving regular showers. He/she said at one time her daughter-in-law would assist due to the facility not bathing the resident regularly. 3. Record review of Resident #73’s face sheet showed the following information: -Readmission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s (MONTH) 2019 shower sheets showed the following the resident received a shower/bed bath on 02/06/19, 02/13/19, 02/20/19, and 02/27/19. Record review of the resident’s (MONTH) 2019 shower sheets showed the following the resident received a shower/bed bath on 03/06/19, 03/11/19, 03/13/19, and 03/27/19. Record review of the resident’s quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene; -Bathing, activity did not occur during this period. Record review of the resident’s care plan, dated 03/24/19, showed the following: -Resident has ADL self-care deficit related to weakness and impaired mobility; -Resident will receive assistance necessary to meet ADL needs; -Assist with daily hygiene, grooming, dressing, oral care, and eating as needed. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0561 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) Record review of the resident’s shower sheets for (MONTH) 2019 showed the following: -Resident received a shower/bed bath on 04/10/19 and 04/24/19; -Resident refused a shower on 04/13/19; -Not applicable was marked on 04/12/19, 04/18/19, 04/19/19, and 04/25/19. Record review of the resident’s shower sheets, dated from 05/01/19 to 05/03/19, did not show any showers/bed baths complete. During an interview on 04/26/19, at 9:32 A.M., the resident said he/she has not been receiving two baths a week since being discharged from hospice in (MONTH) 2019. She would like to have at least two showers a week. 4. During an interview on 05/03/19, at 12:45 P.M., Certified Nurse Aide (CNA) C said he/she assists with showers/bed baths of the 200 hall. He/she is able to complete all his/her baths. He/she will get pulled to the floor, and is currently the only aide on the 200 hall, and will also be assisting with showers. He/she does not mark not applicable on the electronic shower log. He/she does not regularly have residents that refuse showers. Sometimes residents will request their shower at a different time. 5. During an interview on 05/06/19, at 1:18 P.M., CNA J said he/she assists with showers on the 100 hall. He/she normally does not get pulled to the floor, and will sometimes assist staff on other halls with showers. He/she is able to complete all his/her showers. If he/she is unable to, he/she will complete the next day. He/she was marking not applicable on the electronic shower log if a resident received a shower the day before and did not want one on their regularly scheduled day. Management staff have advised for staff not to select the not applicable option. 6. During an interview on 05/06/19, at 3:08 P.M., Registered Nurse (RN) D said residents should receive two showers a week and as needed. The residents have had complaints about not getting their showers. Most days the shower aides are able to keep up, however they do have to occasionally have to pull a shower aide to the floor. He/she tracks the shower sheets. The shower aide brings the shower sheets to RN D at the end of day. Staff should be completing 12 showers a day. Not applicable should not be marked on the electronic shower sheet. He/she is unsure why staff mark that option. An in-service training has been held to advise staff not to mark that option. 7. During an interview on 05/07/19, 9:35 A.M., RN K said shower aides should check resident’s finger nails and trim their nails, if they are not diabetic. Activity staff should also be checking nails when they are painting nails. 8. During an interview on 05/07/19, at 3:19 P.M., the Director of Nursing (DON) said residents should be receiving two showers/bed baths per week. RN D monitors the shower sheets for the front of the facility and RN K monitors the shower sheets for the back of the facility. There is always a shower aide assigned to the hall, and CNA’s can also assist with bathing. He/she is unsure with staff select the not applicable option on the electronic show sheet. MO 975, MO 963, MO 041 and MO 486 | |
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to provide a |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) clean, orderly, homelike environment for when one resident’s (Resident #57) room was not kept clean; when strong urine odors were present on 100 hall; when staff did not clean the dining room in a timely fashion; and when left over trays and lids were stacked on the tables of four residents (Resident #48, #52, #79, and #123). The facility had a census of 142. 1. During an interview on 04/25/19, at 4:05 P.M., with eight members of the resident council, the residents said they were unhappy with the housekeeping. The facility has smells throughout the facility, specifically the 100 and 500 resident halls. Trash cans are not being changed and bathrooms are not being cleaned. The residents have to tell the facility staff to clean the bathrooms. The dining room is not cleaned up on Saturdays and activities are being done without the dining room being cleaned from previous meals. 2. Observation on 4/24/19, at 9:25 A.M., showed a strong urine odor in the common area between the 100 hall entrance and the nurses’ station. Observation on 5/3/19, at 11:40 A.M., showed a strong urine odor on the 100 hall toward a sunroom throughout the length of the hall. At that time, a resident made a face and said, This hall always stinks really bad! Observation on 5/6/19, at 7:25 A.M., showed a strong urine odor in the common area between the 100 hall entrance and the nurses’ station. 3. Observation of Resident #57’s room on 04/25/19, at 10:51 A.M., showed the following: -Privacy curtain drawn, several dried blood stains the size of a dime covering a two feet by two feet area; -Fecal matter on the wall behind the toilet and on the toilet tank around the handle; -Two scratches on the wall, above resident’s bed, approximately 6 to 12 inches long and 6 inches wide. During an interview on 04/25/19, at 10:51 A.M., the resident said the blood stain on the curtain is from at least two months ago. The nurse is aware of the stains and has advised the head housekeeper. He/she said housekeeping staff do not clean the bathroom very good, as he/she has pointed out the fecal matter behind the wall and on the toilet. He/she was advised by housekeeping staff that they clean it the best they can. Observation of the resident’s room on 05/02/19, at 11:05 A.M., showed the following: -Privacy curtain drawn, several dried blood stains the size of a dime covering a two feet by two feet area; -Fecal matter on the wall behind the toilet and on the toilet tank around the handle; -Two scratches on the wall, above resident’s bed, approximately 6 to 12 inches long and 6 inches wide. Observation of the resident’s room on 05/03/19, at 11:26 A.M., showed the following: -Privacy curtain drawn, several dried blood stains the size of a dime covering a two feet by two feet area; -Fecal matter on the wall behind the toilet and on the toilet tank around the handle; -Two scratches on the wall, above resident’s bed, approximately 6 to 12 inches long and 6 inches wide. Observation of the resident’s room on 05/07/19, at 10:16 A.M., showed the following: -Privacy curtain drawn, several dried blood stains the size of a dime covering a two feet by two feet area; -Small amount of fecal matter on the wall behind the toilet and on the toilet tank around the handle; -Two scratches on the wall, above resident’s bed, approximately 6 to 12 inches long and 6 inches wide. During an interview on 05/03/19, at 10:12 A.M., Housekeeping (HK) H said he/she cleans |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) rooms every day. If a door is closed, he/she knocks, and if the resident is not in there he/she will enter the room and clean. No residents on the 200 hall refuse room cleanings, as they all like their rooms cleaned. He/she cleans the bathrooms daily, and will wipe down the toilet and faucets. He/she said maintenance is responsible for removing soiled curtains. He/she will report if a curtain is soiled and needs to be replaced. Deep cleanings are conducted when someone moves out, if someone dies, or as needed. A deep cleaning consists of spraying down the whole room with cleaner, including the bed, TV, walls, and bathroom. During an interview on 05/06/19, at 10:51 A.M., Certified Medication Tech (CMT) A said he/she will advise housekeeping if something in room is dirty, like a privacy curtain or floors. During an interview on 05/06/19, at 11:41 A.M., the Housekeeping Supervisor (HS) said housekeeping cleans rooms daily. They will sweep and mop floor, clean bathrooms, and will clean toilet and surrounding areas. If a privacy curtain in a room is dirty, housekeeping will write down on a board in housekeeping area and he/she or maintenance will change. He/she said the curtains are changed as needed. During an interview on 05/06/19, at 11:43 A.M., HK I said when he/she cleans rooms he/she empties the trash, sweeps and mops floor, and will clean the toilet. If he/she observes a privacy curtain to be soiled, he/she will take it down. During an interview on 05/06/19, at 1:15 P.M., the Maintenance Supervisor said housekeeping or maintenance will change out resident privacy curtains. He/she said housekeeping has a schedule and changes all curtains periodically. During an interview on 05/07/19, at 3:19 P.M., the Administrator said resident rooms should be cleaned daily and privacy curtains should be changed as needed. He/she said it is all of staff’s responsibility; housekeeping, maintenance, nursing staff, to regularly observe a resident’s room to ensure proper cleanliness. 4. Record review of the Meal Service Schedule showed the following: -Lunch service in the East Dining room is at 12:55 P.M.; -Lunch service in the West Dining room is at 12:15 P.M.; -Dinner service in the East Dining room is at 5:55 P.M.,; -Dinner service in the West Dining room is at 5:15 P.M. Observations of the west dining room on 04/25/19, at 5:00 P.M., showed the following: -A large spill, which looked like milk, underneath a table; -Green beans underneath three tables; -Two tables that had white drink spatters on the legs. Observations of the east dining room on 04/25/19, at 5:00 P.M., showed the following: -Several pieces of paper/trash on floor; -A large spill of a clear liquid. Observations of the west dining room on 05/02/19, at 3:02 P.M., showed the following: -Mashed potatoes on the floor; -Brown clumps resembling gravy on the floor; -The table legs of five tables had visibly dirt and white liquid splatters. The legs appeared to be sticky. During an interview on 05/03/19, at 1:14 P.M., HK H said the HS will advise housekeeping staff as to who is responsible for cleaning dining rooms that day. He/she normally cleans the dining room, which consists of wiping down legs of tables. He/she said kitchen staff cleans tops of tables and maintenance cleans the floors. During an interview on 05/06/19, at 11:41 A.M., HS said he/she assigns staff to clean the dining room daily. The dining rooms should be cleaned up between meals. Housekeeping staff |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) sweeps the floors and cleans the table legs. Maintenance runs the floor cleaning machine and dietary staff cleans off the table tops. If there is a spill, housekeeping staff cover the spill with an absorbent pad and then will spot clean spill. During an interview on 05/06/19, at 1:15 P.M., MS said he cleans dining room floors on Mondays and the floor tech cleans the dining room floors on the other days. The dining room floors need to be cleaned after breakfast before activities. Either dietary staff or the floor tech will sweep the floors as needed. Dietary staff will clean the chairs and tables. 5. Observation on 05/01/19, at 1:23 P.M., showed Resident #123 sitting at a four top table by him/herself with approximately 11 trays stacked on his/her table. Observation on 05/02/19, at 1:30 P.M., showed Resident #48 and #79 were sitting at four top table. Staff placed nine trays and four lids on their table while they were eating. Observation on 05/03/19, at 2:08 P.M., showed Resident #123 sitting at a four top table with nine trays and nine lids stacked up in front of where he/she is eating. Observation on 05/06/19, at 1:28 P.M., showed Resident #52 sitting at a four top table with ten trays and ten lids stacked on his/her table while he/she was eating. During an interview on 05/07/19, at 8:27 A.M., Registered Nurse (RN) D said staff should not stack lids or trays on a tables where residents are eating. During an interview on 05/07/19, at 3:19 P.M., the Director of Nursing (DON) said staff should not stack trays or lids on a table while residents are eating. If the resident sits down at a table where trays and lids are already stacked, staff should remove the items. MO 834, MO 938, MO 975, MO 041 and MO 486 | |
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm, saying things to frighten a resident such as telling a Resident that he/she will never be able to see his/her family again; -Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation ; -Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; -All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the administrator, or designated representative; -Should an incident or suspected incident of resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident; -The administrator or designee will complete documentation of the allegation; -Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; and/or (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; -Following completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the employee will be allowed to return to job duties involving resident contact. 1. Record review of the Resident #70’s admission Minimum Data Set (MDS – a federally mandated assessment tool completed by facility staff), dated 3/14/19, showed the following: -admitted to the facility on [DATE] from the hospital; -Resident is cognitively intact; -Resident exhibited no problem behaviors; -Resident has [DIAGNOSES REDACTED]. -Resident takes scheduled and as needed (PRN) pain medications; -Resident experiences frequent pain that makes sleep difficult; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) -Resident rates pain as a ‘5’ (on a scale of 0=no pain to 10=most severe pain). During an interview on 4/26/19, at 11:30 A.M., the resident said the following: -On 4/25/19 at approximately 7:30 P.M., the resident woke up after falling asleep in his/her chair; -The resident was in pain and woke up whimpering; -The resident told Certified Nurse Aide (CNA) Y to let Licensed Practical Nurse (LPN) X know that he/she was in pain; -CNA Y returned and said he/she spoke to LPN X and the nurse said the resident could not have any more pain medication; -The resident said he/she then turned on his/her call light and waited approximately 30-45 minutes for staff to answer the call light; -At approximately 9:30 P.M., LPN X came to the resident’s room and at that point the resident said he/she needed to go the bathroom; -After the resident was assisted to the bathroom,LPN X came in with the resident’s other routine medications and the resident attempted to talk to the nurse about his/her need for pain medication; -The nurse responded by telling the resident he/she had already received his/her pain medications and there was nothing the nurse could do about it; -The nurse then said she was not going to discuss the matter and turned away and walked out of the resident’s room; -The resident said he/she called out to the nurse that she could call the physician and the nurse hollered back that she had already done that; -The resident said he/she then placed a call to his/her family member to discuss the issue; -The resident said while trying to have a private conversation with his/her family member about the issue, the nurse came back into the room and stood, listening to the conversation; -The resident then told the nurse to get out of his/her room and the nurse waved and slammed the resident’s door; -The resident said it is known by the staff that he/she does not like to have his/her door closed; -The resident said he/she then began yelling at the nurse to open the door and the nurse returned and told the resident he/she needed to be quiet; -This angered the resident and he/she began yelling at and cursing the nurse, the nurse then began to yell back at the resident; -The resident said he/she believed other residents and staff heard the yelling; -The resident said no other staff intervened while the nurse yelled at the resident. The allegation of possible abuse was reported to the Director of Nursing (DON) on 4/26/19, at approximately 12:15 P.M. During an interview on 4/26/19, at 3:33 P.M., the DON said the following: -The resident said he/she was angry with LPN X and the LPN pulled the resident’s door shut hard and yelled at the resident; -The resident reported the nurse walked out of the room; -The nurse reported a few minutes later, the nurse re-entered the room while the resident was on the phone and tried to listen in on the resident’s private phone conversation; -The resident said he/she did not report the incident to anyone. During an interview on 4/26/19, at 11:53 P.M., Certified Nurse Aide (CNA) Y said the following; -He/she worked on the night the resident had problems with LPN X; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0600 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) -The CNA said that night, he/she heard LPN X yelling at the resident from up at the nurses’ station while the nurse was halfway down the hall; -The nurse then came to the nurse’s station and said the resident was being a b word and the nurse said she needed to go vape before she knocked the resident out; -The CNA said there were at least two other staff at the desk at the time; -The CNA did not report the incident to administration; -The CNA did not intervene or attempt to stop the staff member from yelling at the resident. During an interview on 4/27/19, at 12:37 A.M., CNA Z said the following: -LPN X was very angry and yelling at the resident; -The nurse was calling the resident names and cursing about the resident at the nurse’s desk; -The nurse said while at the desk, if he/she did not go vape, she was going to slap the resident in the face; -The CNA said he/she did not report the incident, but there were other staff that overheard the nurse’s comments; -The CNA did not intervene or attempt to stop the staff member from yelling at the resident. During an interview on 5/06/19, at 3:55 P.M., RN K said the following: -From now on if resident makes an allegation of abuse or neglect, staff are supposed to report immediately to the RN supervisor/unit manager or the administrator; -The facility has two hours to report the allegation to DHSS. During an interview on 5/07/19, at 11:05 A.M., the DON said the CNAs who overheard LPN X yelling and cursing about the resident, should have intervened and reported the incident immediately. During an interview on 5/07/19 at 3:15 P.M., the administrator said the following: -Staff should report all allegations of resident abuse or neglect immediately to the administrator; -The alleged staff should be immediately suspended pending the completion of the investigation; -The administrator is the facility abuse coordinator. During an interview on 5/07/19 at 3:15 P.M., the facility administrator said the following: -All allegations of abuse/neglect should be reported immediately to the abuse/coordinator which is the administrator; -Any staff member accused of or observed abusing a resident should be immediately suspended, pending the result of the investigation. MO 318, MO 364, MO 384, MO 417 and MO 587 | |
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) selected for review. The facility census was 142. Record review of the facility Abuse and Neglect Prevention Policy and Procedure, revised on (MONTH) (YEAR), showed the following: -Purpose of the is to establish guidelines that prevents, identifies and report resident abuse and neglect; -Policy is for all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident’s medical symptoms. This includes prohibiting nursing facility staff from taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm, saying things to frighten a Resident such as telling a resident that he/she will never be able to see his/her family again; -Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation; -All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative; -All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the state survey agency, not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. -A report shall be made by calling or emailing the survey agency as they have defined to do. 1. Record review of the Resident #70’s admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE] from the hospital; -Resident is cognitively intact; -Resident exhibited no problem behaviors; -Resident has [DIAGNOSES REDACTED]. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) -Resident takes scheduled and as needed (PRN) pain medications; -Resident experiences frequent pain that makes sleep difficult. During an interview on 4/26/19, at 11:30 A.M., the resident said the following: -On 4/25/19 at approximately 7:30 P.M., he/she woke up after falling asleep in my chair; -The resident was in pain and woke up whimpering; -The resident told Certified Nurse Aide (CNA) Y to let Licensed Practical Nurse (LPN) X know that he/she was in pain; -The CNA Y returned and said she spoke to the nurse LPN X and the nurse said the resident could not have any more pain medication; -The resident said he/she then turned on his/her call light and waited approximately 30 to 45 minutes for staff to answer the call light; -At approximately 9:30 P.M., LPN X came to the resident’s room and at that point the resident said he/she needed to go the bathroom; -After the resident was assisted to the bathroom the LPN X came in with the resident’s other routine medications and the resident attempted to talk to the nurse about his/her need for pain medication; -The nurse responded by telling the resident he/she had already received his/her pain medications and there was nothing the nurse could do about it; -The nurse then said she was not going to discuss the matter and turned away and walked out of the resident’s room; -The resident said he/she called out to the nurse that she could call the physician and the nurse hollered back that she had already done that; -The resident said he/she then placed a call to his/her family member to discuss the issue; -The resident said while trying to have a private conversation with his/her family member about the issue, the nurse came back into the room and stood, listening to the conversation; -The resident then told the nurse to get out of his/her room and the nurse waved and slammed the resident’s door; -The resident said it is known by the staff that he/she does not like to have his/her door closed; -The resident said he/she then began yelling at the nurse to open the door and the nurse returned and told the resident he/she needed to be quiet; -This angered the resident and he/she began yelling at and cursing the nurse, the nurse then began to yell back at the resident; -The resident said he/she believed other residents and staff heard the yelling. During an interview on 4/26/19, at 3:33 P.M., the Director of Nursing (DON) said the following: -The resident said he/she was angry with LPN X and the LPN pulled the resident’s door shut hard and yelled at the resident; -The resident reported the nurse walked out of the room; -The nurse reported a few minutes later, the nurse re-entered the room while the resident was on the phone and tried to listen in on the resident’s private phone conversation; -The resident said he/she did not report the incident to anyone. During an interview on 4/26/19, at 11:53 P.M., CNA Y said the following; -He/she worked on the night the resident had problems with LPN X; -The CNA said that night, he/she heard LPN X yelling at the resident from up at the nurse’s station while the nurse was halfway down the hall; -The nurse then came to the nurse’s station and said the resident was being a b word and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0609 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) the nurse said she needed to go vape before she knocked the resident out; -The CNA said there were at least two other staff at the desk at the time; -The CNA did not report the incident to administration. During an interview on 4/27/19, at 12:37 A.M., CNA Z said the following: -LPN X was very angry and yelling at the resident; The nurse was calling the resident names and cursing about the resident at the nurse’s desk; -The nurse said while at the desk, if he/she did not go vape, she was going to slap the resident in the face; -The CNA said he/she did not report the incident, but there were other staff that overheard the nurse’s comments. During an interview on 5/06/19, at 3:55 P.M., Registered Nurse (RN) K said the following: -From now on if resident makes an allegation of abuse or neglect, staff are supposed to report immediately to the RN supervisor/unit manager or the administrator; -The facility has two hours to report the allegation to Department of Health and Senior Services (DHSS). During an interview on 5/07/19, at 11:05 A.M., the DON said the following: -The CNAs who overheard LPN X yelling and cursing about the resident, should have reported immediately. -All allegation of abuse and neglect must be reported to DHSS within 2 hours. During an interview on 5/07/19 at 3:15 P.M., the administrator said the following: -Staff should report all allegations of resident abuse or neglect immediately to the administrator; -The administrator is the facility abuse coordinator. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) Observation on 4/29/19, at 2:48 P.M., showed the resident sat in a wheelchair in his/her room. His/her left great toe appeared black from the tip to the toenail. The resident’s left heel and foot were wrapped in gauze. Record review of the resident’s (MONTH) 2019 physician order [REDACTED]. Record review of the resident’s (MONTH) 2019 Treatment Administration Record showed staff documented completion of left heel wound treatment daily as ordered. Record review of the resident’s current care plan, dated 3/15/19, showed staff did not document information pertaining to a wound on the left heel or the left great toe. 2. Record review of Resident #57’s face sheet (a document that gives a resident’s information at a quick glance) showed the following: -admitted to the facility on [DATE]; -The resident’s [DIAGNOSES REDACTED]. Record review of resident’s nurse’s note dated 11/24/18, at 2:03 A.M., showed staff spoke to resident about leaving the facility. The resident said he/she had gone to the emergency room because he/she was feeling out of control and did not know what else to do. Staff discussed if resident has overwhelming emotions again and feels out of control to notify staff in order to help. Resident understood and agreed. Record review of resident’s nurse’s note dated 11/24/18, at 8:58 A.M., showed staff interviewed the resident at this time in regard to leaving facility and feeling out of control. The resident said he/she gets nervous and feels like they are going to explode so he/she just walks. Staff explained they would like to help and the resident needs to let staff know how they are feeling. Record review of the resident’s social service note dated 11/24/18, at 9:18 P.M., showed staff educated resident on the facility leave of absence policy. Record review of resident’s care plan, dated 11/24/18, showed the following: -Resident has habit of signing self out and leaving facility; -He/she likes to walk when he becomes stressed. He/she usually walks to nearby store or will walk to Walmart; -Resident will be able to leave as desired to stress relief without event; -Encourage resident to notify staff when leaving; -Encourage resident to talk to staff prior becoming too stress that he has to leave facility; -Target date 03/12/19. Record review of nurse’s notes dated 11/25/18, at 9:16 P.M., showed resident was on leave of absence from the facility and returned after he/she attended church and watched movies with his friends. Record review of resident’s care plan, dated 11/26/18, showed the following: -Resident is an elopement risk/wanderer with a history of attempts to leave facility unattended, not sign out, impaired safety awareness; -The resident will not leave the facility unattended through the review date; -Identify pattern of wandering; -Target date 03/12/19. Record review of the resident’s social service notes dated 11/27/18, at 5:38 P.M., showed staff met with resident to ensure he/she remembered to sign out and let staff know if he/she is leaving the building. Record review of resident’s nurse’s note dated 12/01/18, at 11:02 P.M., showed the resident left the facility at 6:15 P.M. to attend a play and returned at 10:30 P.M. Record review of resident’s social services note dated 12/26/18, at 10:45 A.M., showed staff asked the resident where he/she was on the evening of 12/24/18. The resident said |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) he/she left the facility to visit a friend and to attend late church. The resident advised he/she told the nursing staff where he/she was going and signed out. 3. During an interview on 05/07/19, at 1:18 P.M., Social Services (SS) said care plan goals should coincide. He/she reviews the care plans to make ensure they do not have conflict information. 4. During an interview on 05/07/19, at 1:18 P.M., the MDS Coordinator said care plans that are due for review are discussed that month at the weekly care plan meeting with the interdisciplinary team (IDT). The IDT will review care plans to ensure there is no conflicting information. 5. During an interview on 05/07/19, at 3:30 P.M., the Administrator said care plans should not have conflicting information. | |
| F 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) Observation on 4/29/19 showed the following: -At 1:05 P.M., the resident sat in his/her wheelchair at a dining room table; -The resident’s immobile right arm rested on a half tray connected to the wheelchair; -The resident’s plate held a small biscuit and plain iceberg lettuce. The resident also had a small bowl of stew, a piece of cake in a Styrofoam bowl, an unopened packet of salad dressing, and an unopened tub of butter on his/her table; -The resident did not have any drinks on his/her table; -The resident attempted to eat plain lettuce off a plate with his/her left fingers; -The resident attempted to eat a few bites of the stew with a fork using his/her left hand, but was unable to get any meat or vegetables to stay on the fork; -At 1:10 P.M., a certified nursing assistant (CNA) walked over to the resident’s table and handed the resident an open carton of milk with no glass or straw; -The CNA said to the resident, If you need anything else, let me know, and walked away; -The resident looked confused, but attempted to drink the milk from the carton out of the side of the open spout, milk spilled down the resident’s chin; -The resident attempted to get a bite of cake out of the Styrofoam bowl, but was unable to. The resident dumped the cake out of the bowl onto the plate and ate the cake with his/her fingers; -The CNA did not offer to put salad dressing on the resident’s salad; did not offer to cut, open, or butter the biscuit; did not offer the resident a cup of a straw for the carton of milk; and did not offer the resident a spoon for the stew; -At 1:15 P.M. a CNA asked from approximately 10 feet away if the resident is doing okay, the resident nods his/her head up and down; -At 1:20 P.M., the resident has consumed approximately approximately 25 % of his her lunch and drank most of the carton of milk; -A CNA walked up behind the resident and pulled the resident away from the table without speaking to the resident; -The CNA propelled the resident to the hallway near the nurse’s station and left the resident. Observation on 4/30/19, at 12:40 P.M., showed the following: -The resident lay in bed asking if staff were getting him/her up out of bed for lunch. Observation on 4/30/19, at 1:20 P.M., showed the following: -The resident lay in bed with the head of the bed elevated approximately 30 degrees; -Staff had positioned the resident’s over bed table across the resident’s bed; -No staff were present to assist the resident or to monitor for swallowing problems; -The plate held a slice of plain bread, an unopened tub of butter, buttered pasta with no sauce, and ground meat with stewed chunks on the meat, the resident had a glass of lemonade to drink; -The resident attempted to eat the pasta with a fork, but the pasta slid around the resident’s plate. Observation and interview on 5/01/19, at 1:15 P.M., showed the following: -The resident lay in bed with a lunch tray on the over bed table across the resident’s bed; -The resident ate stuffing covered with gravy and a dry roll, the resident pointed to the meat and asked this surveyor what it was, when the surveyor replied pork roast, the resident shoved the entire over table away from the bed and frowned; -The resident indicated he/she did not like pork because of religious reasons; -The resident indicated no staff had asked the resident about his/her food preferences; -No staff were present to assist the resident, offer an alternative, or monitor the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) resident for swallowing problems. Observation on 5/02/19, at 12:15 P.M., showed the following: -The resident lay in bed, alone in the room with the tray table across the bed with a lunch plate which held chicken, peas, and carrots, and a slice of bread; -The resident’s drinks were out of his/her reach. -The resident’s call light was connected to the bed frame below the level of the mattress on the right side, out of the resident’s sight and reach. During an interview on 5/07/19, at 8:20 A.M., the Speech Therapist (ST) JJ, said the resident needs supervision and cueing with meals and assistance with opening containers and cutting up food. During an interview on 5/07/19, at 11:05 P.M., the Director of Nursing (DON) said all staff should ensure the resident’s call light is in the resident’s reach before leaving the resident’s room. During an interview on 5/07/19, at 3:15 P.M., the administrator and DON said the following: -A nurse should be present in the dining room during meals; -Staff should assist residents with opening containers, pouring milk into glasses, and with dining assistance if needed during meals. MO 938 and MO 041 | |
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide appropriate treatment and care according to orders, resident’s preferences and goals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) comprehensive assessment tool completed by facility staff), dated [DATE], showed no PICC line or IV medication. Record review of the resident’s care plan, dated [DATE], showed a care plan entry for the PICC line. Staff did not address how often to change the PICC line dressing on the care plan. Record review of the resident’s admission note dated [DATE], at 7:28 P.M., showed the following: -Resident was alert and oriented x 4; -Resident had multiple bruises over abdomen at different healing stages; -Port for [MEDICAL TREATMENT] (a process where wastes, salts, and fluid are filtered from blood when kidneys are no longer healthy enough to do this work adequately): Right tunneled intra-jugular (IJ) catheter (a thin tube that is placed under the skin in a vein, most commonly in the neck) placed [DATE]. Left SVC Powerline Double Lumen (a PICC line with two separate tubings leading into the same line) placed [DATE]. Record review of the resident’s (MONTH) 2019 and (MONTH) 2019 treatment administration record (TAR) showed: -No order to change the PICC line dressing in (MONTH) or (MONTH) 2019; -No documentation of the PICC line dressing being changed in either (MONTH) or April. Record review of the resident’s [MEDICAL TREATMENT] Communication Record, dated [DATE], showed a note from a [MEDICAL TREATMENT] nurse to the facility which showed, Also concerned about Patient’s PICC line dressing. Has not been changed since it was placed. Who is responsible of changing that dressing? Record review of the resident’s nurse’s note dated [DATE], at 2:17 P.M., showed staff returned call to [MEDICAL TREATMENT] about PICC line. Notified nurse that staff are removing here at facility. Resident has completed antibiotic therapy and is being discharged on [DATE] to home health care. During an interview on [DATE], at 11:37 A.M., the admissions nurse said the following: -Every new admission with a PICC line gets a dressing change the day after admission and every seven (7) days; -Any time a resident with a PICC line was admitted , orders are added that say to change dressing every seven days and flush line every shift. If the admission came during a shift he/she wasn’t working the floor, nurses might not know to put the order in; however, they should know to do the actual tasks. During an interview on [DATE] at 2:05 P.M. Registered Nurse (RN) D said: -Dressing changes to PICC line can be done by the RN only. If there is not an RN available to change the dressing, one of the unit managers will do it; -Dressings to PICC lines and central lines are to be changed every seven days; – If a resident admits to the facility and no orders to change the dressing are sent from the hospital, they are put in place upon admission. During an interview on [DATE], at 3:15 P.M., the Director of Nursing (DON) said: -PICC line dressing should be changed within the first 24 hours of admission then weekly and as needed; -RNs only change the PICC line dressing; -She was unaware of the communication from [MEDICAL TREATMENT] regarding the resident. 2. Record review of the Resident #93’s face sheet (gives basic information) showed the following: -admitted to the facility [DATE]; -Admitting [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS] ([MEDICAL CONDITION]). Record review of the resident’s current care plan, reviewed on [DATE], showed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) following: -On [DATE], actual impairment to skin integrity of the abdomen related to surgical wound, small bowel resection hernia repair with infected mesh; -On [DATE], goal of skin injury abdominal wound to be healed; -On [DATE], interventions of monitor and document location, size and treatment of [REDACTED]. Record review of the resident’s (MONTH) 2019 physician order [REDACTED]. -An order dated [DATE], for treatment to midline incision wound abdomen. Treatment ordered included cleanse with normal saline (NS), apply wet/dry (moistened, not dripping) Kerlix (gauze) rol in wound bed, cover with ABD (gauze) pad, secure with [MEDICATION NAME] (breathable, flexible) tape; every day and evening shift; -An order dated [DATE], for treatment to drain tube of right lower abdomen. Treatment ordered flush with 5 to 10 cubic centiliters (cc) NS, every shift; -An order dated [DATE], for treatment to small abdominal wound. Treatment ordered included clean with normal saline (NS), apply moistened ,[DATE] inch packing gauze in wound, cover with gauze, and secure with [MEDICATION NAME] (breathable, flexible) tape every day and evening shift. Record review of the resident’s (MONTH) 2019 treatment administration record (TAR) showed the following: -An order dated [DATE], clarified [DATE], for treatment to drain tube of right lower abdomen. Treatment included measure output and flush with 5 to 10 cc NS every shift. Staff did not document completion of the treatment on 4 of 22 opportunities; -An order dated [DATE], for treatment to small abdominal wound. Treatment included clean with NS, apply moistened ,[DATE] inch packing gauze in wound, cover with gauze, secure with [MEDICATION NAME] tape every day and evening shift. Staff did not document completion of the treatment on 4 of 22 opportunities; -An order dated [DATE], for treatment to midline incision wound abdomen. Treatment included apply wet/dry (moistened, not dripping) Kerlix rol in wound bed, cover with ABD pad, secure with [MEDICATION NAME] tape; every day and evening shift. Staff did not document completion of the treatment on 4 of 22 opportunities. Record review of the resident’s (MONTH) 2019 TAR showed the following: -An order dated [DATE], clarified [DATE], for treatment to the drain tube of the right lower abdomen. Treatment included measure output and flush with 5 to 10 cc NS every shift. Staff did not document completion of the treatment on 14 of 60 opportunities; -An order dated [DATE], for treatment to small abdominal wound. Treatment included clean with normal saline (NS), apply moistened ,[DATE] inch packing gauze in wound, cover with gauze, secure with [MEDICATION NAME] tape, every day and evening shift. Staff documented did not document completion of the treatment on 12 of 60 opportunities; -An order dated [DATE], for treatment to midline incision wound abdomen. Treatment included apply wet/dry (moistened, not dripping) Kerlix rol in wound bed, cover with ABD pad, secure with [MEDICATION NAME] tape, every day and evening shift. Staff did not document completion of the treatment on 12 of 60 opportunities; During an interview on [DATE], at 10:40 A.M., the resident said staff did not always change his/her wound dressing and empty the drain tube as directed by the physician’s orders [REDACTED]. Record review of the resident’s current care plan, reviewed on [DATE], showed the following: -On [DATE], infection of the abdominal wall; -On [DATE], goal for resident to be free from complications related to infection; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) -On [DATE], interventions of administer antibiotic as per physician orders, maintain universal precautions when providing resident care. Record review of the resident’s (MONTH) 2019 TAR showed the following: -An order dated [DATE], for treatment to drain tube of the right lower abdomen. Treatment included measure output and flush with 5 to 10 cc NS every shift. Staff did not document completion of the treatment on 3 of 18 opportunities. During an interview on [DATE], at 1:45 P.M., RN K said the floor nurses should complete all treatments per physician orders. The nurse should document the treatment on the TAR and note any descriptions in a progress note. During an interview on [DATE], beginning at 3:16 P.M., the Director of Nursing (DON) said the nurses were responsible for completing all dressing changes and other treatments according to the physician orders. The nurse should document the treatment on the TAR and make notes in the progress notes. 3. Record review of Resident #134’s face sheet showed the following information: -admitted to the facility [DATE]; -[DIAGNOSES REDACTED]. -discharged to the mortician [DATE] at 10:15 A.M. Record review of an Outside the Hospital Do-Not Resuscitate (DNR) Order showed the resident’s next of kin signed the form on [DATE]. The attending physician for the skilled nursing facility signed the form on [DATE]. Record review of a County Medical Examiners Office document entitled Notification of Death in a Nursing Facility showed the following information: -Admission Diagnosis: [REDACTED]. -No fall, accident, or unusual event while at facility; -Not on hospice services; -date of death : [DATE]; -Time of death: 9:15 A.M. Record review of the resident’s progress notes showed an admission note that included the following: -admitted after a fall at home resulting in [MEDICAL CONDITION]; -Alert and oriented only to self; nonverbal and unable to make needs known; -Next of kin stated resident was walking and talking prior to fall; -Assessment showed lungs clear, breathing even and unlabored, oxygen saturation at 94% on room air, heart rate 93 with regular rate and rhythm, denies pain or shortness of breath; -Discussed code status with family; elected to sign DNR form, sent to physician for signature. Record review of the resident’s progress notes showed staff did not document information pertaining to the resident’s death. During an interview on [DATE] at 2:25 P.M., the medical records personnel said no written documentation pertaining to the resident’s death was found in the closed medical record, with the exception of the coroner notice. During an interview on [DATE], at 3:50 P.M., the Director of Nursing (DON) said he/she was unable to locate any nurses’ notes pertaining to the resident’s death. He/she did not recall any details regarding the event. He/She would expect the nurse to document a narrative regarding a death. During an interview on [DATE] at 1:45 P.M., RN K said two nurses must assess a resident and determine death has occurred. A nurse should notify the physician and resident’s family and document the event in progress notes. During an interview on [DATE] at 10:55 A.M., LPN M said if a resident expires in the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) facility, a staff member should check the resident’s code status to determine whether or not to begin or continue coronary [MEDICAL CONDITION] resuscitation (CPR). Staff should record a time line of events and document the information in the progress notes. 4. Record review of Resident #94’s admission MDS, dated [DATE], showed the following: -Resident re-entered the facility from the hospital on [DATE]; -Cognitively intact; -No behaviors; -Required extensive assistance of one staff with bed mobility, transfers, dressing, personal hygiene, and toileting; -Always continent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of the resident’s current care plan, revised on [DATE], showed the following: -Resident has potential for impairment to skin integrity related to [MEDICAL CONDITION] and impaired mobility; -Encourage good nutrition and hydration in order to promote healthier skin; -Identify and document potential causative factors and eliminate/resolve where possible; -Weekly treatment documentation to include measuring each area of skin breakdown, type of tissue, exudate, and any other notable changes in observations; -Monitor/document/report any signs and symptoms of skin problems: redness, [MEDICAL CONDITION], blistering, itching, burning, bruises, cuts, other [MEDICAL CONDITION]. Record review of the resident’s physician order [REDACTED]. -An order dated [DATE], for [MEDICATION NAME] powder (an antifungal medicated powder) 100,000 units/gram, apply to rash topically every six hours as needed for rash. Record review of the resident’s (MONTH) 2019 TAR showed the following: -An order dated [DATE], for [MEDICATION NAME] Powder 100,000 units/gram, apply to rash topically every 6 hours as needed for rash; -No nurses initialed completion of the treatment in (MONTH) 2019. Record review of the resident’s (MONTH) 2019 TAR showed the following: -An order dated [DATE], for [MEDICATION NAME] Powder 100,000 units/gram, apply to rash topically every 6 hours as needed for rash; -No nurses initialed completion of the treatment in (MONTH) 2019. During an interview and observation on [DATE], at 2:30 P.M., the resident said the following: -The resident has a yeast infection to his/her groin; -The resident cannot get staff to put medicine on the area; -Staff brought the resident a bottle of [MEDICATION NAME] powder; -The resident cannot put the powder on and needs assistance with it; -The resident said his/her groin had, Really gotten bad; -The resident said the yeast infection areas on his/her groin and inner thighs drain fluid and the fluid gets the resident’s pants wet; -A small bottle of [MEDICATION NAME] powder sat on the resident’s over bed table. During an interview on [DATE], at 12:45 P.M., the resident said the following: -The resident ran out of [MEDICATION NAME] powder approximately two to three days prior; -The resident said he/she informed the nurses of the need to order [MEDICATION NAME] powder. During an interview on [DATE], at 12:50 P.M., Licensed Practical Nurse (LPN) NN said the resident does not have a skin treatment to his/her groin. Record review of the resident’s (MONTH) 2019 TAR showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) -An order dated [DATE] for [MEDICATION NAME] Powder 100,000 units/gram, apply to rash topically every 6 hours as needed for rash; -No nurses initialed completion of the treatment in (MONTH) 2019. Observation and interviews on [DATE], at 11:05 A.M., showed the following: -Certified Nurse Aide (CNA) P and CNA OO entered the resident’s room to assist the resident with changing his/her pants; -The resident had peeling skin and redness to his/her inner upper thighs bilaterally, and to his/her anterior and posterior groin; -The resident said the areas are painful; -The resident said staff are not performing treatments to the areas; -CNA P said the resident did have [MEDICATION NAME] powder in his/her room in the past for staff to apply to the yeast infected areas. During an interview on [DATE], at 11:05 P.M., the DON said the following: -She was not aware of any skin issues with the resident’s groin. -The wound nurse should be checking all of the residents’ skin on a weekly basis and documenting the findings. MO 938, MO 963, MO 428, MO 429, and MO 467 | |
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate pressure ulcer care and prevent new ulcers from developing. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) -Staging classification: the following staging classification is consistent with the national pressure ulcer advisory panel (NPUAP). A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction; -Stage 1 pressure ulcer: Non-blanchable (a reddened area that does not temporarily turn white or pale when pressure is applied; usually a result of impaired circulation) [DIAGNOSES REDACTED] (redness) of intact skin; -Stage 2 pressure ulcer: Partial-thickness skin loss with exposed dermis; -Stage 3 pressure ulcer: Full thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue (formation of new tissue, usually pink to red in color) and epibole (rolled wound edges) are often present. Slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and/or eschar (dead or devitalized tissue that is hard or soft in texture) may be visible. The depth of tissue damage varies by anatomical location. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure ulcer; -Stage 4 pressure ulcer: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure ulcer; -Unstageable pressure ulcer: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. 1. Record review of Resident #95’s admission record showed the following: -admitted to the facility on [DATE] from the hospital; -[DIAGNOSES REDACTED].), reduced mobility, and adult failure to thrive. Record review of the resident’s physician order [REDACTED]. -Order for intravenous piggyback (IVPB) medication infusion of meropenem ([MEDICATION NAME]) (an antibiotic) staff to administer 1000 milligrams (mg) every 8 hours for wound infection for 27 days; -Order for IVPB medication [MEDICATION NAME] (antiinfective) 1750 mg one time a day for wound infection for 27 days; -Negative pressure wound therapy 150 millimeters (mm)/mercury (hg) every day shift Monday and Thursday for wound care; -Daily-Vite (multi-vitamin) tablet give one tablet by mouth one time a day for supplement; -Zinc sulfate tablet 110 mg give one tablet one time daily for supplement; -Regular diet with double portions and high protein diet with supplements. Record review of the resident’s pressure injury risk assessment, dated 2/28/19, showed the resident is a moderate risk. Record review of the resident’s nursing admission screening/history, signed 3/01/19, showed the following: -admitted from the hospital; -Reason for admission was wound care and intravenous (IV) antibiotic therapy; -Sacral ulcer; -Stage 4 pressure ulcer to sacrum measured 13 centimeters (cm) in length by 15 cm in width by 6 cm in depth; -Right ischial (hip bone) pressure ulcer (no stage listed) 7.0 cm in length by 7.0 cm in |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) width by 6.0 cm in depth with an irregular shape. Record review of the resident’s weekly wound observation, dated 3/01/19, completed by the facility wound nurse, showed the following: -Stage 4 pressure ulcer sacrum to left buttock to ischial area; -Slough tissue present (yellow, tan, white, stringy); -Unable to determine the extent of necrosis and/or slough in the wound bed; -Scant amount of serosanguineous drainage; -No odor to wound; -Wound measurements: 13.0 cm in length by 15.0 cm in width by 6.0 cm in depth; -Peri-wound pink blanching normal in color; -Wound edges and shape are irregular; -Current treatment plan: [REDACTED] -Wound present on admission. Record review of the resident’s physician order [REDACTED]. -An order dated 3/4/19, for negative pressure wound therapy 150 mm/hg every day shift every Monday and Thursday for wound care. Record review of the resident’s admission minimum data set (MDS – a federally mandated assessment tool completed by facility staff), dated 3/07/19, showed the following: -Severe cognitive impairment; -Did not reject care; -Required extensive assistance of 2 or more staff with bed mobility, dressing, toileting, and personal hygiene; -Impaired range of motion to both lower extremities; -Wheelchair for mobility; -Has one stage 3 pressure ulcers, 2 stage 4 pressure ulcers and 2 unstageable pressure ulcers; -Pressure reducing device to chair and bed; -Staff apply dressings and ointments/medications to resident’s skin. Record review of the resident’s nutritional assessment, dated 3/07/19, completed by the dietitian, showed the following: -Plan/recommendations to change daily vite to multivitamin with minerals, evaluate the discontinuation of zinc sulfate after 14 days use, start Prosource 30 milliliters (ml) two times per day, and draw [MEDICATION NAME] lab. Record review of the skin observation tool, dated 3/08/19, completed by the facility wound nurse, showed the following: -Resident frequently complains of discomfort with wounds, he/she has additional wound report. Record review of the resident’s weekly wound observation, dated 3/08/19, completed by the facility wound nurse, showed the following: -Stage 4 sacral pressure ulcer; -Overall impression, wound is improving; -[MEDICATION NAME] tissue present (pink); -Granulation tissue present (beefy red); -Slough tissue present (yellow, tan, white, stringy); -5% necrosis and/or slough in the wound bed; -Scant amount of serosanguineous drainage; -No odor to wound; -Wound measurements: 15.0 cm in length by 15.0 cm in width by 5.0 cm in depth; -Peri-wound pink blanching normal in color; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 25) -Wound edges and shape=irregular at one edge and well defined on the other edge; -Current treatment plan: [REDACTED] -Wound present on admission; -Slowly improving cleaner than previous. Record review of the resident’s weekly wound observation, dated 3/08/19, completed by the facility wound nurse, showed the following: -Stage 3 right gluteal/posterior thigh pressure ulcer; -Overall impression, wound is improving; -Granulation tissue present (beefy red); -Scant amount of serosanguineous drainage; -No odor to wound; -Wound measurements: 5.5 cm in length by 4.4 cm in width by 2.0 cm in depth; -Peri-wound pink blanching, no increased temperature; -Wound edges and shape=rolled, well defined; -Current treatment plan: [REDACTED] -Resident non-compliant with leaving dressing intact, will begin peeling at dressing immediately upon completion; -Cleaner than previously observed. Record review of the resident’s care plan, dated 3/13/19, showed the following -Has nutritional problem or potential nutritional problem related to alteration in skin integrity related to pressure ulcers; -Administer medications as ordered; -Obtain and monitor lab and diagnostic work as ordered. Report results to the resident’s physician and follow up as indicated; -Provide and serve diet as ordered. Record review of the resident’s weekly wound observation, dated 3/15/19, completed by the facility wound nurse, showed the following: -Stage 3 coccyx (tailbone) pressure ulcer; -Overall impression, unchanged; -Visible tissue moist; -5% necrosis and/or slough in the wound bed; -Scant amount of serous drainage; -No odor to wound; -Wound measurements: 15.0 cm in length by 14.6 cm in width by 5.0 cm in depth; -Peri-wound pink blanches; -Wound edges and shape=rolled; -Current treatment plan: [REDACTED] -Wound progress= little change. Record review of the skin observation tool, signed 3/17/19, completed by the facility wound nurse, showed the following: -Resident frequently complains of discomfort with wounds, he/she has additional wound report. Record review of the resident’s weekly wound observation, dated 3/17/19, completed by the facility wound nurse, showed the following: -Stage 3 right posterior thigh pressure ulcer; -Overall impression, wound is improving; -Visible tissue moist -Scant amount of serous drainage; -No odor to wound; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 26) -Wound measurements: 4.3 cm in length by 5.6 cm in width by 1.8 cm in depth; -Peri-wound pink blanching, no induration; -Wound edges and shape=rolled; -Current treatment plan: [REDACTED] -Cleaner than previous. Record review of the resident’s (MONTH) 2019 physician order [REDACTED]. -A order dated 3/18/19, for Prosource (nutritional supplement) give 30 ml by mouth three times per day. (This order came 11 days after dietitian recommendation to start Prosource.) Record review of the resident’s care plan, revised on 3/20/19, showed the following: -Resident has (multiple) pressure ulcers; -Assess/record/monitor wound healing sacrum, both hips, left buttock, right heel; -Measure length, width, and depth where possible; -Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician; -Follow facility policies/protocols for the prevention/treatment of [REDACTED].>-Monitor/document/report as needed any changes in skin status: appearance, color, wound healing signs/symptoms of infection, wound size (length by width by depth), and stage. Record review of the skin observation tool, dated 3/28/19, completed by the facility wound nurse, showed the following: -Resident states he/she always hurts. Record review of the resident’s 30-day MDS, dated [DATE], showed the following: -Resident admitted to the facility on [DATE]; -Moderately impaired cognitive ability; -Exhibits inattention and disorganized thinking, behaviors present, fluctuate (comes and goes, changes in severity); -Delusions; -Verbal behavioral symptoms directed toward others and not directed toward others, occurred 4-6 days in a week, but less than daily; -Rejection of care 4-6 days in a week; -Required extensive assistance of one staff with bed mobility, dressing, toileting, and personal hygiene; -Transfers, activity only occurred once or twice, resident required assistance of two or more staff; -Functional limitation in range of motion or both lower extremities; -Wheelchair for mobility device; -[DIAGNOSES REDACTED]. -Resident has one stage 3 pressure ulcer, two stage 4 pressure ulcers, and two unstageable pressure ulcers; -Resident has pressure reducing device for chair and bed; -Resident takes as needed pain medication for frequent pain, rates pain a 6 on a scale of 0-10. Record review of the resident’s physician order [REDACTED]. -An order dated 3/28/19, for treatment to coccyx/sacrum and right gluteal fold. Treatment included [DEVICE] negative pressure therapy 150 mm/hg every day shift every Monday and Thursday on the day shift for wounds related to pressure ulcer of sacral region, stage 4. Record review of the resident’s care plan, revised on 3/31/19, showed the following: -Resident is resistive to [DEVICE] at times as well as removing dressings; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 27) -Allow the resident to make decisions about treatment regime, to provide a sense of control; -Give clear explanation of all care activities prior to and as they occur during each contact. Record review of the resident’s (MONTH) 2019 Registered Nurse (RN)/Licensed Practical Nurse (LPN) Medication Administration Record [REDACTED] -Nurses failed to sign administration of the resident’s Meropenem 1000 mg per IV ordered every 8 hours for wound infection for 27 days (beginning on 2/28/19); -Nurses failed to sign administration of the Meropenem 6:00 A.M., dose on 3/14/19, 3/19/19, and 3/27/19; -Nurses failed to sign administration of the Meropenem 2:00 P.M. dose on 3/05/19, 3/06/19, 3/10/19, 3/15/19, 3/16/19, and 3/18/19-3/23/19; -Nurses failed to sign administration of the Meropenem 10:00 P.M. dose on 3/11/19, 3/14/19, and 3/25/19; -Staff did not document the reason for the missed doses. Record review of the skin observation tool, dated 4/05/19, completed by the facility wound nurse, showed the following: -Coccyx wound was 9.4 cm in length by 12 cm in width by 3.4 cm in depth, red beefy granulation wound base, tunnel at 9 o’clock 2.2 cm depth; -Right ischial wound was 4.2 cm in length by 1.3 cm in width by 0.1 cm in depth, red beefy wound base. Record review of the resident’s laboratory results, dated 4/08/19, showed the following: -Resident’s white blood cell count result of 7.9 K/UL (reference range 4.0-10.00) result is in normal range. Record review of the resident’s weekly wound observation, signed 4/15/19, completed by the facility wound nurse, showed the following: -Stage 4 coccyx pressure ulcer; -Overall impression, improving; -Granulation tissue present (beefy red) and moist; -No necrosis and/or slough in the wound bed; -Moderate amount of serosanguineous (containing or consisting of both blood and serous fluid) drainage; -No odor to wound; -Wound measurements: 9.2 cm in length by 11.5 cm in width by 3.4 cm in depth; -Peri-wound pink blanching normal in color; -Wound edges and shape=well defined; -Current treatment plan: [REDACTED] -Wound progress= healing. Record review of the resident’s weekly wound observation, signed 4/15/19, completed by the facility wound nurse, showed the following: -Stage 4 right ischial pressure ulcer; -Overall impression, wound is improving; -Visible tissue granulation tissue present (beefy red) and moist; -Moderate amount of serosanguineous drainage; -No odor to wound; -Wound measurements: 4.0 cm in length by 3.2 cm in width by 3.6 cm in depth; -Peri-wound pink blanching, normal in color; -Wound edges and shape= well defined; -Current treatment plan: [REDACTED] |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 28) -Wound progress= healing. Record review of the resident’s physician progress notes [REDACTED]. -Resident was seen and examined today. Resident continues to tolerate wound vac. Strong odor noticeable. No concerns or new events reported by the nursing staff; -Skin color, texture, turgor normal. No rashes or [MEDICAL CONDITION], sacral wound not assessed; -Assessment and plan: infected sacral pressure ulcer and right ischial pressure ulcer and probable osteo[DIAGNOSES REDACTED] sacrum; -status [REDACTED].>-Completed [MEDICATION NAME] (and IV [MEDICATION NAME]; -Continue [DEVICE]; -Follow up with wound clinic and infectiousdisease. Record review of the resident’s progress note dated 4/18/19, at 1:53 P.M., showed a nurse documented the following: -Resident returned from the infectious disease physician office on 4/17/19 with the following note from the physician indicating the wounds are doing well and to call for an appointment if the wounds are doing poorly. The resident’s FNP notified of the report, no new orders at this time. Record review of the resident’s family nurse practitioner (FNP) progress note, dated 4/18/19, showed the following: -Resident was seen and examined today. Resident is up in a wheelchair. Resident denies any specific complaints. Pain is controlled. Resident continues to tolerate the [DEVICE]. Encouraged offloading to his/her sacral wound as the resident has been up in a wheelchair 10 or more hours per day for the past two weeks. No concerns or new events reported by the nursing staff; -Skin color, texture, turgor normal. No rashes or [MEDICAL CONDITION], sacral wound with [DEVICE] in place and declining per nursing report, no signs of infection; -Assessment and plan: Infected sacral pressure ulcer and right ischial ulcer and probable osteo[DIAGNOSES REDACTED] sacrum -status [REDACTED].>-Completed [MEDICATION NAME] and IV [MEDICATION NAME]; -Continue wound VAC; -Follow up with wound clinic and ID. Record review of the resident’s weekly wound observation, signed 4/19/19, completed by the facility wound nurse, showed the following: -FNP notified of wound status deterioration on 4/19/19 (Friday); -Stage 4 coccyx pressure ulcer; -Overall impression, worsening; -Granulation tissue present (beefy red) and moist; -Necrotic tissue present (brown, black, leather, scab-like); -Resident noted with three necrotic areas to wound base related to extended time in the wheelchair, refusing to lie down; -5% necrosis and/or slough in the wound bed; -Moderate amount of serosanguineous drainage; -Odor present to wound; -Wound measurements: 11.0 cm in length by 11.0 cm in width by 3.5 cm in depth; -No tunneling or undermining; -Peri-wound pink blanches normal in color and temperature; -Wound edges and shape=well defined; -Current treatment plan: [REDACTED] -Wound progress= Wound has deteriorated with 3 necrotic areas at 8 o’clock 1.5 cm by 1.4 |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 29) cm, at 6 o’clock 2.0 cm by 3.5 cm by 2.0 cm, center of wound base 4.0 cm by 0.4 cm black to gray line; -Continue to educate resident to the need of relieving pressure to area at least every two hours. Resident will respond, I know, but I’m tired and don’t want to spend my life in bed. Record review of the resident’s weekly wound observation, signed 4/19/19, completed by the facility wound nurse, showed the following: -FNP notified of wound status deterioration on 4/19/19; -Stage 4 right ischial pressure ulcer; -Overall impression, wound is improving; -Visible tissue [MEDICATION NAME] tissue present (pink); -Small amount of serosanguineous drainage; -Wound measurements: 4.4 cm in length by 2.5 cm in width by 5.6 cm in depth; -Peri-wound pink blanching, normal in color and temperature; -Wound edges and shape= well defined; -Current treatment plan: [REDACTED] -Wound progress= showing reserved progress at this time. Record review of the resident’s nurse progress notes dated 4/22/19, at 3:54 P.M., showed the wound nurse documented the following: -[DEVICE] dressing change this date; -Resident noted to have dark necrotic increase to surface of coccyx wound; -Resident educated that the wound has deteriorated related to his increased amount of time in wheelchair and decline request from staff to lay down and relieve pressure to coccyx wound; -Wound has foul odor and increased drainage; -Notified the resident’s physician of the wound and requested lab and culture of wound with next [DEVICE] change. Record review of the resident’s physician progress notes [REDACTED]. -Skin color, texture, turgor normal, no rashes or [MEDICAL CONDITION], sacral wound not assessed but reportedly stable; -Assessment and plan: Infected sacral pressure ulcer and right ischial ulcer and probable osteo[DIAGNOSES REDACTED] sacrum -status [REDACTED].>-Completed [MEDICATION NAME] and IV [MEDICATION NAME] -Continue wound VAC; -Follow up with wound clinic and ID. Record review of resident’s care plan, dated 4/23/19, showed the following -Resident is non-compliant with cares, will refuse dressing changes, will loosen and try to pull [DEVICE] off, resident will stay up in wheelchair for hours and refuses to lay down to take pressure off his coccyx/sacral area; -Educate the resident on the consequences of his noncompliance with relieving pressure, allowing the dressing changes to be done as ordered; -Encourage the resident to lay down frequently during the day. Record review of the resident’s nurse progress notes dated 4/23/19, at 8:22 A.M., showed the following: -Physician order [REDACTED]. Record review of the resident’s nurse progress notes, dated 4/23/19, showed the following: -At 1:03 P.M., a nurse documented he/she called the wound clinic to set up an appointment for the resident and left a message for a return call; -At 2:28 P.M., a nurse documented the wound clinic returned call and would send paperwork |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 30) for the facility to fill out and return to set up an appointment for the resident. Record review of the resident’s laboratory results, dated 4/23/19, showed the following: -The resident’s white blood cell count result of 13.3 K/UL (cubic millilieter) (reference range 4.8-10.8) result is above normal range. Record review of the resident’s nurse progress notes dated 4/24/19, at 8:36 A.M., showed the following: -A nurse documented paperwork completed and faxed back to the wound clinic, waiting for the wound clinic to review and give appointment for wound clinic. During an interview on 4/24/19, at 10:15 A.M., the RN Q, the facility wound nurse, said the following: -The wound nurse completes one hall of skin assessments/wound assessments/treatments per day; -The wound nurse attempts to get to each hall in the facility (except the dementia unit) one day per week; -The resident had multiple pressure ulcers on admission; -The resident currently has a stage 4 pressure ulcer to his/her coccyx and a stage 4 pressure ulcer to his/her right ischium, both with current treatments for [DEVICE]; -The facility is attempting to set up an appointment for the wound clinic because the coccyx wound is deteriorating. During observation and interview on 4/24/19, at 11:50 A.M., the resident lay in bed and a strong foul odor permeated the resident’s room. The resident said he/she spoke to the administrator because some of the nurses were refusing to change his/her pressure ulcer dressings. The resident said the issue is better. Observation and interview on 04/25/19, at 11:15 A.M., showed the following: -A foul odor present in the hallway outside of the resident’s room. Upon entering the room the smell became very strong; -RN Q entered the resident’s room to perform wound care to the resident’s pressure ulcers; -The resident’s existing [DEVICE] dressing appeared displaced and rolled off halfway (dated 422), a persistent odor of rotten eggs permeated the room; -The RN removed the resident’s [DEVICE] dressing exposing a coccyx pressure ulcer presenting as a deep crater, the approximate diameter of a cantaloupe and a right ischial pressure ulcer presenting as a golf ball sized opening to a tunneling wound; -The RN measured the resident’s coccyx pressure ulcer as 12.4 centimeters (cm) in length by 14.0 cm in width by 3.0 cm in depth, with undermining from 9 to 10 o’clock with an undermining lateral distance of 4.2 cm. The wound nurse described the wound base as 30% necrotic tissue and 50% yellow slough. The peri-wound showed an area of redness spreading out from the entire circumference of the wound measured approximately 3.0 cm wide; -The RN said he/she was trying to get information to the wound clinic for a referral; -The RN said the resident’s coccyx wound showed major deterioration within the past 5 days; -The RN said the resident had a misunderstanding about the appropriate amount of time to be up in a wheelchair; -The RN measured the resident’s right ischial pressure ulcer as 3.5 cm in length by 5 cm in width by 5.2 cm in depth with pink tissue to the wound; -The RN said the resident removes his/her pressure ulcer dressings at times and at times the dressings come loose during transfers/re-positioning; -During the dressing change, the wound nurse cut black [DEVICE] foam to fit into the coccyx pressure ulcer and placed the foam into the wound with gloved hands. The nurse’s gloved fingers touched the pressure ulcer wound bed. The wound nurse then covered the foam |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 31) with clear adhesive. Without washing or sanitizing his/her hands, the wound nurse picked up another piece of black foam wearing the same gloves and cut and placed the foam into the ischial pressure ulcer. The nurses’ gloved fingers touched the pressure ulcer wound bed. The nurse then covered the foam with wounds then covered second wound with clear adhesive. The nurse then removed his/her gloves and cleaned his/her hands with alcohol gel; -The RN nurse said the resident’s physician looked at pictures of the resident’s pressure ulcers on 4/23/19. The wound nurse said he/she took the photos on Thursday 4/18/19 and Monday 4/22/19. The RN said the physician looked at the photos and ordered a wound consult and a culture and sensitivity of the wound drainage; -The RN said he/she consistently measured the pressure ulcers weekly, except for a period of time in March, 2019 when the facility had staffing issues and the wound nurse was pulled to work the floor as a charge nurse for three weeks; -The RN said he/she noted an odor to the resident’s coccyx pressure ulcer on Thursday 4/18/19 and a deterioration in the appearance of the resident’s coccyx pressure ulcer on Monday, 4/22/19. The pressure ulcer had an increased odor and an increase in the amount of necrotic tissue. During an interview on 4/26/19, at 9:50 A.M., Certified Nursing Assistant (CNA) P said the following: -The CNA said he/she could smell the odor of the resident’s pressure ulcer in the resident’s room and outside of the resident’s room into the hall for approximately the last one and one-half weeks; -The CNA said the odor has continued to get worse. During an interview on 4/26/19, at 10:15 A.M., the RN Q said the following: -He/she just heard from the resident that the [DEVICE] needed changed and this is the first the nurse knew about it; -The wound nurse said he/she spoke to the resident’s physician on Monday 4/22/19 to notify him/her of the condition of the resident’s pressure ulcer and the physician ordered wound cultures and the lab picked up the wound cultures this AM on 4/26/19; -The lab drew blood work for ordered lab tests on Tuesday 4/23/19, but the nurse was unsure if the physician or nurse practitioner were aware of the results; -The wound clinic called with an appointment scheduled for the resident, but the wound clinic first available appointment is not until 5/10/19 (in two weeks from now). During an observation on 4/26/19, at 10:20 A.M., the wound nurse informed the Director of Nursing (DON) of the date of the resident’s wound clinic appointment and the DON asked if the resident’s physician could get the resident into the wound clinic sooner and the wound nurse said, no the physician could not get the resident in sooner. During an interview on 4/26/19, at 10:25 A.M., the DON said the following: -The DON said he/she makes rounds with the wound nurse every now and then; -The DON said he/she saw part of the resident’s pressure ulcer on Monday night, 4/22/19; -The DON said the resident’s dressing was coming off and the coccyx wound had an odor and gray eschar covered approximately 80 % of the wound bed; -The DON said he/she worked as a charge nurse on the evening shift, but he/she did not change the dressing, but passed it on to the night shift that the resident’s dressing needed changed; -The DON said, other than that night, he/she had never seen the resident’s pressure ulcers; -The DON said he/she had never spoken the resident’s physician or nurse practitioner about the resident’s pressure ulcers. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0686 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 32) During an interview on 4/26/19, at 10:55 A.M., RN K said the following: -He/she had never personally seen the resident’s pressure ulcers, but has viewed pictures of the pressure ulcers; -The RN said the resident received IV antibiotics from the time of admission, but when the IV antibiotics were finished the resident started getting out of bed more; -The RN said he/she believes the combination of being off the antibiotics and being out of bed more (increased pressure to the ulcers) has led to a decline of the pressure ulcers; -The RN said the resident’s coccyx pressure ulcer has necrotic tissue and an odor that it probably did not have one week ago; -The RN said the resident’s physician asked if he could see the resident’s pressure ulcer and the wound nurse took a picture of her cell phone and showed the photo to the physician, approximately three to four days ago, the RN said that was the same day that the physician gave orders for a wound culture; The RN said the resident’s coccyx pressure ulcer has had an odor for approximately 2 weeks, but in the past week the odor has gotten really bad; -The RN said he/she believes the resident’s family nurse practitioner has looked at his/her pressure ulcers. During an interview on 4/26/19, at 1:22 P.M., the resident’s FNP said the following: -The FNP has | |
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 33) -An order dated 4/18/19, to change Foley catheter monthly for infection for prevention. Observation on 5/6/19, at 3:17 P.M., showed Certified Medication Tech (CMT) N and LPN O washed their hands and donned gloves prior to providing personal care to the resident, stating the resident’s catheter was possibly leaking. CMT N and LPN O assisted the resident to turn to his/her right side. CMT N rolled a saturated sheet and bed pad inside toward the resident, tucking them under him/her. Without changing gloves or performing hand hygiene, CMT N placed a clean sheet and bed pad on the bed, tucking them under the resident as far as possible. CMT N and LPN O assisted the resident to turn over to his/her left side. LPN O removed the wet sheet and bed pad. Without changing gloves or performing hand hygiene, LPN O unrolled and positioned the clean sheet and bed pad and assisted the resident to turn onto his/her back. Still wearing the same contaminated gloves, LPN O secured the catheter tubing with his/her left hand and used his/her right hand to clean the catheter tubing. During an interview on 5/7/19, at 11:05 A.M., Certified Nurse Aide (CNA) P said staff should wash their hands and don gloves prior to performing catheter care. Staff should remove their gloves and wash their hands prior to proceeding to any other body part or other task. During an interview on 5/7/19, at 3:16 P.M., the Director of Nursing (DON) said staff should wash their hands upon entering a resident’s room and prior to performing any care. After completing the catheter care, staff should remove their gloves and wash or sanitize their hands before touching other things or proceeding to another task. | |
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide enough food/fluids to maintain a resident’s health. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 34) based on the RD’s recommendations. Record review of the resident’s annual Minimum Data Set (MDS – a federally mandated comprehensive assessment tool completed by facility staff), dated 3/19/19, showed the following: -Severe cognitive impairment; -Needs supervision, oversight, encouragement or cueing for eating, and requires one-person physical assist for eating. Record review of the resident’s care plan, last revised on 3/28/19, showed the following: -History of involuntary weight loss related to inadequate oral intake, as evidenced by greater than 5% weight loss in one month; -Staff is to encourage and assist as needed to consume foods and or supplements and fluids offered, honor food preferences, provide diet as ordered, provide supplements as ordered, review weights, and notify physician and responsible party of significant weight changes. Record review of the resident’s vital signs showed the following: -On 4/11/19, the resident weighed 111.2 pounds. Record review of the resident’s progress note dated 4/19/19, at 9:08 A.M., showed a note by the RD that resident is at 111.2 pounds with 8.9 pound loss in one month, 12.4 pound loss in 3 months, and 15.9 pound loss in 6 months. Further loss is undesired. Diet is mechanical soft with Ensure Plus twice daily. The RD recommended to change Ensure Plus to 90 ml Med Pass Supplement three times daily and add a multi vitamin with minerals secondary to weight loss. Record review of the resident’s Order Summary Report showed no new orders were entered based on the RD’s recommendations. 2. Record review of Resident #117’s face sheet showed the following: -Admission on 8/24/16; -[DIAGNOSES REDACTED]. Record review of the resident’s vital sign charting showed the following: -On 10/3/18, the resident weighed 203.5 pound. Record review of the resident’s (MONTH) 2019 POS for (MONTH) 2019 showed the following orders: -An order dated 11/9/18, for nutritious Juice (a calorie rich, vitamin and protein enhanced juice drink), six ounces with meals; -An order dated 11/11/16, for regular diet with regular liquids. Record review of the resident’s vital sign charting showed the following: -On 1/16/19, the resident weighed 185.2 pounds. Record review of the resident’s progress notes dated 3/22/19, at 12:12 P.M., showed the RD noted resident at 180.2 pounds with a six pound loss in one month, 10.1 pound loss in 3 months, and 18.7 pound loss in 6 months. Further loss is undesired. The RD recommended to change Nutritious Juice to 90 ml Med Pass Supplement twice daily. Monitor for weight stabilization. Record review of the resident’s Order Summary Report showed no new orders were entered to indicate the RD’s recommendations were followed. Record review of the resident’s quarterly MDS, dated [DATE], showed the following: -Cognition severely impaired; -Needs limited assistance with activities; -Staff provides guided assistance and one person physical assistance with eating. Record review of the resident’s care plan, last updated 4/17/19, showed: -At risk for weight loss related to cognitive deficit; -Staff was to honor food preferences, provide diet as ordered; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 35) -Resident to go to restorative dining; -Staff to review weights and notify the physician and responsible party of a significant weight change. Record review of the resident’s vital sign charting showed on 4/18/19 the resident weighed 177.4 pounds. Record review of the resident’s progress notes dated 4/20/19, at 8:21 A.M., showed a note by the RD that resident is 177.4 pounds with a loss from 203.5 pounds since October. Further loss is undesired. The RD recommended Nutritious Juice changed to 90 ml Med Pass Supplement three times daily to mitigate (make less severe) further weight change. Monitor weight pattern, intake, and skin. Record review of the resident’s Order Summary Report showed no new orders were entered to indicate the RD’s recommendations were followed. 3. Record review of Resident #242’s face sheet showed the following: -Admission on 2/20/19; -[DIAGNOSES REDACTED]. Record review of the resident’s vital signs showed the following: -On 2/20/19, the resident weighed 96.1 pounds; -On 2/28/19, the resident weighted 94.3 pounds. Record review of the resident’s care plan, last updated 3/5/19, showed: -Required tube feeding related to dysphagia (difficulty swallowing); -Elevate the head of the bed 45 degrees during and for thirty minutes after tube feeding; -Staff to check for tube placement and residual (left over) volume per facility protocol and record; -RD to evaluate quarterly and as needed. Monitor caloric intake, estimate needs, and make recommendations for changes to tube feeding as needed; -Speech Therapy evaluation and treatment as ordered. Record review of the resident’s vital signs showed: -On 3/14/19, the resident weighed 91.7 pounds. Record review of the resident’s 30-day Scheduled Assessment MDS, dated [DATE], showed: -Cognition severely impaired; -Needs extensive physical assist with all Activities of Daily Living (ADLs); -Had a feeding tube and received 51% or more of daily caloric intake through the tube. Record review of the resident’s vital signs showed: -On 3/28/19, the resident weighed 89.5 pounds. Record review of the resident’s progress motes dated 3/29/19, at 7:45 P.M., showed the RD noted resident is at 89.5 pounds with a loss from 96.1 pounds in one month. Further loss is undesired. Receives [MEDICATION NAME] 1.5 Calorie at 48 ml/hr until 960 ml infused with 42 ml/hour auto flush. Recommended changing tube feeding to [MEDICATION NAME] 1.5 Calorie at 50 ml/hr until 1000 ml infused with 42/ml hour auto flush. New regimen would provide 1500 calories, 63.8 g protein, and 1900 ml fluid per day. Record review of the resident’s vital signs showed the following: -On 4/11/19, the resident weighed 84.9 pounds. Record review of resident’s hospital records titled Nutrition Focused Physical Exam-Summary, dated 4/13/19 at 10:28 A.M., showed: -Dietitian assessment of severe protein-calorie; -Severe fat loss; -Muscle wasting assessment showed severe; -Weight loss greater than 7.5% in three months (severe). Record Review of the resident’s hospital notes dated 4/13/19, at 11:03 A.M., showed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 36) resident’s family member told the nurse that the facility had only been feeding the resident 50 ml every 12 hours. The family member had a picture of the tube feeding that was labeled open 3/31 and the photograph was taken on 4/3 with only about 400 ml missing from the bottle. Record review of the resident’s Order Recap Report, dated 4/3/19, showed an order for [REDACTED]. 5. During an interview on 5/6/19, at 2:05 P.M., RN K said tube feeding is expected to run the directed amount of time. The RD made recommendations to increase tube feeding. The RD recommendations were put in place immediately for Resident #242. RN K said it felt like the amount should have been raised a little more. The RD that is currently contracted has never been in the facility. The Director of Nursing (DON) emails the RD with issues regarding tube feedings. Risk Management meetings are on Wednesdays to discuss weight loss, antibiotics, falls, or anything of concern. If someone has weight loss the unit managers usually tell the doctors. 6. During an interview on 5/07/19, at 11:05 P.M., the Director of Nursing said the following: -Staff should change out the resident’s Kangaroo bag at least every 48 hours and each nurse shift should check the tube feeding and document on the amount of tube feeding administered; -The administration record should prompt nurses on every shift about the tube feeding orders. 7. During an interview on 5/07/19, at 1:20 P.M., the facility medical director said the following: -The facility should notify a resident’s physician of any dietary recommendations made the RD; -The facility staff should administer tube feeding to a resident as ordered. MO 938 and MO 975 | |
| F 0693 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0693 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 37) physician orders dated 4/11/19: -Regular diet, mechanical soft texture; -Flush enteral tube with 30 milliliters (ml) of water pre/post medication administration and 5-10 ml between each medication; -Every shift, nurse to check feeding tube residual volume; -One time a day intermittent pump enteral feeding: Formula Glucerna 1.5 at 60 ml/hour (hr) until 1200 ml infused with 60 ml/hr autoflush of water. (The resident’s enteral pump feeding for 20 out of every 24 hours at 60 ml/hr to equal 1200 ml.) Record review of the resident’s care plan, dated 4/11/19, showed the following: -Resident requires tube feeding related to dysphagia (difficulty or discomfort in swallowing); -The resident needs the head of bed elevated 45 degrees during and thirty minutes after tube feed; -Staff to check for tube placement and gastric contents/residual volume per facility protocol and record; -Speech therapy evaluate and treat; -Resident has an activities of daily living (ADL – dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to [MEDICAL CONDITION] (paralysis of one side of the body) and stroke diagnoses; -Resident has a communication problem related to [MEDICAL CONDITION] (loss of the ability to produce and/or comprehend language, due to injury to brain areas); -Staff to anticipate and meet needs; -Resident is able to nod head yes or no. Record review of the resident’s admission nurse note dated 4/12/19, at 9:11 A.M., showed the following: -Late entry for 4/11/19 at 11:40 P.M.; -Resident arrived from the hospital; -admission orders [REDACTED] -Resident is non-verbal, but is able to follow conversation and make needs known by nodding or shaking head; -Resident has PEG (feeding) tube with tube feeding of Glucerna 1.5 hung and started at 60 ml/hour and water flushes as per orders. Record review of the resident’s (MONTH) 2019 treatment administration record (TAR) showed the following: -Order dated 4/11/19, for every shift to check peg tube residual volume (aspiration of stomach contents to determine amount of liquid remaining in stomach); -Nurses to initial three times per day at 6:30 A.M., 2:30 P.M., and 10:30 P.M.; -Nurses failed to document the residual checks on 4/13/19, 4/15/19, 4/17/19 at 2:30 P.M., 4/25/19 at 2:30 P.M., and 4/28/19 at 6:30 A.M. Record review of the resident’s (MONTH) 2019 TAR for (MONTH) 2019 showed the following: -Order dated 4/12/19, for one time a day intermittent pump enteral feeding: formula, Glucerna 1.5 at 60 ml/hr until 1200 ml infused with 60 ml/hr autoflush; -Nurses to initial daily at 7:00 P.M. (the order contains no stop time); -Nurses failed to document the administration of the resident’s enteral feedings on 4/13/19, 4/15/19 through 4/17/19, 4/25/19, and 4/29/19. Record review of the resident’s admission Minimum Data Set (MDS – a comprehensive assessment tool completed by facility staff), dated 4/18/19, showed the following: -Severe cognitive impairment; -Disorganized thinking, behavior present, fluctuates (comes and goes); |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0693 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 38) -Required extensive assistance of two or more staff with bed mobility; -Required extensive assistance of one staff with transfers, dressing, eating, toileting, and personal hygiene; -Functional limitation in range of motion, upper extremity and lower extremity impairment on one side; -[DIAGNOSES REDACTED]. -Resident has feeding tube and consumes mechanically altered diet for nutritional needs; -Receives physical therapy (PT), occupational therapy (OT), and speech therapy (ST), five times per week each. Record review of the resident’s nutritional assessment, dated 4/18/19, completed by the dietitian, showed the following: -Diet order of mechanical soft and Glucerna 1.5 calorie at 60 ml/hr until 1200 ml infused with 60 ml/hr autoflush; -No known food allergy; -Monitor intake; -Resident receives tube feeding and oral diet; -No evidence of skin breakdown; -Regimen is supportive of needs, but would change tube feeding to Glucerna 1.5 240 ml bolus three times per day after meals if consumes less than 50 % of meals, Glucerna 1.5 ml at 60 ml/hr from 10:00 P.M. until 6:00 A.M. (480 ml infused), flush feeding tube with 200 ml of water every four hours. New regime to allow for increased oral intake if resident is accepting. Observation on 4/24/19, at 3:15 P.M., showed the following: -The resident lay awake on the bed on his/her back; -A full pre-filled bottle of Glucerna 1.5 (a high calorie nutritional formula) hung in the resident’s room with approximately 1200 ml remaining in the bottle, dated 4/23/19 at 7:00 P.M. (20 hours prior), with the tubing inserted into the bottle, but not attached to the resident; -The tube feeding pump was turned off; -A full bag of water hung in the resident’s room, undated and not attached up to the resident. (A bottle of 1200 ml running at 60 ml/hr, hung at 7:00 P.M., should have completely infused in 20 hours.) Observation on 4/26/19, at 10:50 A.M., showed the following: -A bottle of Glucerna 1.5 hung in the resident’s room with approximately 525 ml remaining in the bottle, dated 4/23/19 at 7:00 P.M. (3 days prior) with tubing inserted into bottle, but not hooked up to the resident; -The tube feeding pump was turned off; -A bag of water containing approximately 500 ml remaining in the bag hung in the resident’s room, dated 4/25/19 at 7:00 P.M., and not hooked up to the resident. (A bottle containing 1200 ml running at 60 ml/hr, hung at 7:00 P.M. on 4/23/19 should have completely infused in 20 hours on 4/24/19 at approximately 3:00 P.M.) Observation in the resident’s room on 4/29/19, at 1:25 P.M., showed the following: -A bottle of Glucerna hung in the resident’s room with approximately 550 ml remaining in the bottle, dated 4/28/19 and no time, with tubing inserted into the bottle; -The tube feeding pump was turned off; -A bag of water hung in the resident’s room with approximately 400 ml remaining in the bag, dated 4/28/19. (A bottle of 1200 ml running at 60 ml/hr, hung at 7:00 P.M., should have completely |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0693 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 39) infused in 20 hours.) -The resident sat in the hallway. Observation on 5/02/19 showed the following: -At 8:20 A.M., a bottle of Glucerna hung in the resident’s room with approximately 550 ml remaining in the bag, dated 4/30/19 at 9:30 P.M., with tubing inserted; -The tube feeding pump was turned off; -A bag of water hung in the resident’s room with approximately 400 ml remaining in the bag, dated 4/29/19 at 7:00 P.M.; -At 10:30 A.M., the resident lay in bed, the tube feeding remained disconnected and turned off. (A bottle of 1200 ml running at 60 ml/hr, hung on 4/30/19 at 9:30 P.M., should have completely infused in 20 hours on 5/01/19.) During an interview on 5/02/19, at 10:35 A.M., Licensed Practical Nurse (LPN) MM said the following: -The day shift nurses do not administer the resident’s tube feeding, it is evening or night shift’s responsibility; -The nurse said the resident only gets one medication and 30 ml of water thru the feeding tube during the day. During an interview on 5/02/19, at 10:45 A.M., Registered Nurse/Unit Manager (RN) K said the following: -He/she does not know the resident’s tube feeding orders; -He/she does not know if the dietitian sees the resident; -If the RD makes a recommendation, RN K sends it to the Director of Nursing (DON). During an interview on 5/02/19, at 11:24 A.M., the DON said the following: -The resident’s feeding tube would need to run for 20 out of 24 hours to administer the ordered amount; -Dietitian recommendations first go to the dietary manager, then to the DON; -If the resident needs a new diet or tube feeding order, the DON contacts the physician. During an interview on 5/02/19, at 12:30 P.M., the dietary manager (DM) said the following: -The facility previously had a full time RD, who left in (MONTH) 2019; -Since the beginning of the year, the dietitian reviews the resident’s charts remotely and does not generally come to the facility to see residents. During an interview on 5/06/19, at 3:55 P.M., RN K said the following: -The resident’s tube feeding orders came from the hospital; -If the RD makes a recommendation, RN K generally finds the recommendations when auditing the progress notes; -He/she unaware of any recommendations to change the resident’s tube feedings; -He/she does not know the resident’s current tube feeding orders; -He/she expects nurses to replace bottles of Glucerna and bags for water at least every 24 hours; -He/she said she does not follow up to ensure nurses are giving the residents their ordered tube feedings; -After reviewing the resident’s current orders, RN K said the resident should be hooked up to the tube feeding all the time except for 4 hours during the day for meals and therapy. During an interview on 5/07/19, at 11:05 P.M., the DON said the following: -Staff should change out the resident’s Kangaroo bag at least every 48 hours and each nurse shift should check the tube feeding and document on the amount of tube feeding administered; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0693 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 40) -The administration record should prompt nurses on every shift about the tube feeding orders. During an interview on 5/07/19, at 1:20 P.M., the facility medical director said the following: -The facility should notify a resident’s physician of any dietary recommendations made the RD; -The facility staff should administer tube feeding to a resident as ordered. | |
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide safe and appropriate respiratory care for a resident when needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 41) The resident’s [DIAGNOSES REDACTED]. Record review of the resident’s care plan, revised on 02/13/19, staff did not care plan the use of oxygen. Record review of the resident’s 60 day MDS, dated [DATE], showed the following information: -Cognitively intact; -Oxygen therapy. Record review of the resident’s POS, dated 05/07/19, showed the following: -Two liters of oxygen per minute via nasal cannula for [MEDICAL CONDITION], start date 08/23/18; -No order was present indicating the frequency staff should replace the nasal cannula/tubing. Observation on 04/25/19, at 03:48 P.M., showed the resident in bed, receiving 2.5 liters oxygen, via nasal cannula. No date was present on the oxygen tubing. Observation on 05/03/19, at 02:05 P.M., showed the the resident in bed, receiving 2.5 liters oxygen, via nasal cannula. No date was present on the oxygen tubing. During an interview on 05/03/19, at 2:05 P.M., the resident said he/she tells the aide whenever he/she needs it changed. He/she states staff will change it every month or two. The last time it was changed was about three weeks ago. Record review of the resident’s TAR, dated 05/07/19, showed no scheduled change in oxygen tubing. 3. Record review of Resident #112’s face sheet showed the following: -admitted on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident’s 14 day MDS, dated [DATE], showed: -Cognitively intact; -Requires extensive assist with transfers, activities of daily living (ADLs-dressing, grooming, bathing, eating, and toileting) and locomotion (movement from one place to another); -Resident receives oxygen and [MEDICAL CONDITION] (an opening through the neck into the windpipe to provide and airway and to remove secretions). Record review of the resident’s POS showed a current order for oxygen at three liters per cannula. Observation on 4/26/19, at 9:30 A.M., showed the resident’s oxygen tubing had no date written on it. The resident’s oxygen humidifier bottle was empty and had no date on it. During an interview on 04/26/19, at 9:30 A.M., the resident said the oxygen tubing gets changed about every month. It was last changed approximately two weeks ago. 4. During an interview on 05/02/19, at 10:37 A.M., Registered Nurse (RN) D said night nursing staff change the oxygen tubing. 5. During an interview on 05/03/19, at 9:00 A.M., the Director of Nursing (DON) said there is no documentation of staff changing oxygen tubing. The night nurses change the tubing once a wk. 6. During an interview on 05/03/19, at 11:07 A.M., CNA C said he/she does not know when oxygen tubing needs to be changed, but he/she will change the tubing if a resident requests it. MO 938 and MO 233 |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | ||
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide safe, appropriate pain management for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 43) Record review of the resident’s nursing admission screening/history, signed 3/01/19, showed the following: -admitted from the hospital; -Oriented to person, place, and time; -Reason for admission was wound care and intravenous (IV) antibiotic therapy; -Resident has pain rated as a ‘9’ on the numeric rating scale with 1=mild pain to 10=worst possible pain. Location of pain is bilateral lower extremities and wounds (pressure ulcers). Record review of the resident’s care plan, dated 3/01/19, showed the following: -Has chronic pain related to chronic physical disability, [MEDICAL CONDITION], and wounds; -Staff to administer [MEDICATION NAME] ([MEDICATION NAME]) as per orders; -Anticipate the residents need for pain relief and respond immediately to any complaint of pain. Record review of the resident’s (MONTH) 2019 Registered Nurse (RN)/Licensed Practical Nurse (LPN) Medication Administration Record [REDACTED].M., staff documented administration of one dose of [MEDICATION NAME] 10/325 mg for complaints of pain rated as an ‘8’ with effective results. Record review of the resident’s activities progress note dated 3/01/19, at 8:59 A.M., completed by the activity assistant showed the following: -The resident said he/she would like a pain pill; -The resident said when he/she asked the nurse, the nurse said no and was very rude; -The activity assistant spoke to the resident’s nurse and then returned to the resident’s room and informed the resident is was too early for a pain pill; -The resident became angry and said he/she had not yet asked for a pain pill; -The resident then pulled the blanket over his/her head. (Nursing staff did not document about the resident’s request for pain medication). Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED] -On 3/02/19, nurses did not document administration of any PRN [MEDICATION NAME] for pain to the resident; -On 3/02/19, nurses did not document a pain assessment for the resident. Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED] -On 3/02/19, at 6:30 A.M., a certified medication technician (CMT) documented the resident’s pain level at a ‘7’; -Staff did not document any pain interventions. Record review of the resident’s physician progress notes [REDACTED].M., showed the following: -physician’s orders [REDACTED]. Record review of the facility’s narcotic receipt packing slip, signed on 3/05/19, showed the following: -The facility received a card of 30 tablets of [MEDICATION NAME] 10/325 mg on 3/05/19 for the resident; Record review of the resident’s admission minimum data set (MDS – a federally mandated assessment tool completed by facility staff), dated 3/07/19, showed the following: -Severe cognitive impairment; -Inattention, behavior present, fluctuates (comes and goes); -Experiences delusions; -Exhibits behavioral symptoms toward others; -Staff administer pain medications as needed (PRN); -Staff did not utilize non-medication interventions for pain; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 44) -Pain is frequent and rated as a ‘7’. Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED] -On 3/08/19 at 6:30 A.M., a CMT documented the resident’s pain at a 7; -Staff did not document any pain interventions related to the resident’s complaint of pain. Record review of the skin observation tool dated 3/08/19, at 8:49 A.M., completed by the facility wound nurse, showed the following: -Resident frequently complains of discomfort with wounds; -Staff did not document any pain interventions related to the resident’s complaint of pain. Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED] -On 3/08/19, the resident complained of pain at 6:30 A.M. and at 8:49 A.M.; -On 3/08/19, the nurse administered a pain pill ([MEDICATION NAME] 10/325 mg) to the resident 9:40 P.M. (over 15 hours after the first complaint of pain. Record review of the skin observation tool dated 3/15/19, at 8:49 A.M., completed by the facility wound nurse, showed the following: -Resident frequently complains of discomfort with wounds; -Staff did not document any pain interventions related to the resident’s complaints of discomfort. Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED] -On 3/15/19, the resident complained of discomfort at 8:49 A.M.’ -Staff administered pain medication at 6:21 P.M. for resident’s for complaints of pain rated as a ‘7’ with effective results (a nine hour delay in medication administration). Record review of the resident’s nurse progress note dated 3/22/19, at 3:15 P.M., showed the nurse entered the resident’s room to let him/her know the nurse was working on getting his/her pain medications and the facility had notified the resident’s physician of the need to fax a script to the pharmacy. The resident became upset about it and stated he/she just did not understand. The nurse attempted to explain to the resident that sometimes the physicians do not get things done in a timely fashion and the resident acknowledged understanding. The nurse did not document any other pain interventions for the resident. Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED] -On 3/22/19, at 7:11 P.M., the resident rated his/her pain level as an ‘8’ and staff administered a pain pill, nearly 4 hours after the resident’s request for pain medication. Record review of the resident’s nurse progress notes, dated 3/26/19 at 5:26 A.M., showed the following: -The resident requested his/her pain medication early; -The nurse instructed the resident that the pain medication is to be given every six hours only; -The nurse did not document any other attempted pain intervention. Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED] -On 3/26/19 at 8:45 P.M., the resident rated his/her pain as a 7 and staff administered a pain pill ([MEDICATION NAME]), 15 hours after the resident’s original request for pain medication; Record review of the resident’s skin observation tool dated of 3/28/19, at 8:56 A.M., completed by the facility wound nurse, showed the following: -Resident states he/she always hurts; -The wound nurse did not document any other attempted pain interventions or address the resident’s pain. Record review of the resident’s 30-day minimum data set (MDS), dated [DATE], showed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 45) following: -Resident admitted to the facility on [DATE]; -Moderately impaired cognitive ability; -Resident takes as needed pain medication for frequent pain, rates pain a 6 on a scale of 0-10. Record review of the resident’s family nurse practitioner (FNP) progress note, dated 4/18/19, showed the following: -Resident denies any specific complaints. Pain is controlled. Resident continues to tolerate the [DEVICE]; -Encouraged offloading to his/her sacral wound as the resident has been up in a wheelchair 10 or more hours per day for the past 2 weeks; Observation and interview on 4/25/19, at 11:15 A.M., showed the following: -Registered Nurse (RN) Q entered the resident’s room to complete wound care; -During the dressing change, the resident cried out and said, It hurts! and the wound nurse replied, I’m sure it does. -The resident rated his/her pain as an 8 on a scale of 1-10. -During the dressing change, the resident made a grunting noise. The nurse asked the resident if he/she was okay and the resident responded he/she was hurting. The nurse responded by telling the resident, You are being really patient with me and I appreciate it. (The nurse did not stop to administer pain medication to the resident and did not pretreat the resident for the pain.) During an interview on 4/26/19, at 9:50 A.M., Certified Nurse Assistant (CNA) P said the resident complain of pain all the time, once the resident wakes up, he/she is in constant pain. During an interview on 4/26/19, at 10:55 A.M., the RN K said the facility has an issue with having pain medications available for the residents. During an interview on 4/26/19, at 1:22 P.M., the resident’s family nurse practitioner (FNP) said the following: -The FNP said the resident’s pain level is no different than normal for the resident; -The FNP said he/she did not know if the resident was experiencing pain to the pressure ulcer, he/she would have to ask the resident. 2. Record review of Resident #70’s admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE] from the hospital; -Resident is cognitively intact; -Resident has [DIAGNOSES REDACTED]. -Resident takes scheduled and as needed (PRN) pain medications; -Resident experiences frequent pain that makes sleep difficult; -Resident rates pain as a ‘5’ (on a scale of 0=no pain to 10=most severe pain). Record review of the resident’s nurse’s progress notes dated 3/15/19, at 12:30 P.M., showed a nurse documented the following: -Contacted the resident’s physician related to resident complaints of [MEDICAL CONDITION] (weakness, numbness, and pain from nerve damage) and pain and requested that [MEDICATION NAME] (anticonvulsant) order be clarified and changed back to the dosage the resident was taking at home, as well as request to increase the resident’s pain medication; -The physician gave orders to increase the resident’s [MEDICATION NAME] to 800 mg four times a day and gave an order for [REDACTED].>-The nurse faxed the orders to the pharmacy. Record view of the resident’s medication review report showed the following current |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 46) orders: -Order dated 3/15/19 for [MEDICATION NAME] 15 mg, give 0.5 tablet (to equal 7.5 mg) by mouth every four hours as needed for diabetic [MEDICAL CONDITION] or pain; -Order dated 3/15/19 for [MEDICATION NAME] 800 mg, give one tablet by mouth four times a day related to diabetes with diabetic [MEDICAL CONDITION]. Record review of the resident’s nurse progress note dated 3/16/19, at 10:39 A.M., showed a nurse documented the following: -Off-going nurse reported that he/she had called the pharmacy to relay new orders of an increase dosage in the resident’s PRN [MEDICATION NAME] as well as requested to pull the medication from the emergency kit at the facility; -The pharmacy denied the facility’s request; -The nurse placed two calls to the resident’s physician and left messages for return call regarding the need for pharmacy communication; -The nurse provided the resident with a PRN Tylenol and the medication was determined to be effective as the resident is sleeping. Record review of the resident’s nurse progress notes dated 3/16/2019, at 10:04 P.M., showed the following: -The nurse went into the resident’s room to give his/her medications; -The nurse had to wake the resident up to give the medications and check the resident’s blood sugar; -The resident did not complain of pain to the nurse all shift; -The resident asked if his/her pain pills were at the facility yet, and the nurse told the resident they were not; -The nurse explained to the resident that there is nothing the nurse can do to further help the situation of pain pills; -The pharmacy will not dispense the resident’s pain medications because the facility received 60 pills the previous day and then the physician discontinued that order upon resident request, because he/she wanted a higher dosage of pain medication; -The resident has slept all shift other than when he/she had to be woke up for medications and blood sugar checks along with insulin administration; -The nurse notified the DON; -The nurse spoke with the resident’s family member who stated he/she would be at this facility in the morning to come up with a solution to correct the problem of pain medications. Record review of the resident’s care plan, revised on 3/21/19, showed the following: -Resident has chronic pain related to arthritis and diabetic [MEDICAL CONDITION]; -Staff to administer pain medications as per orders; -Evaluate the effectiveness of pain interventions, review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; -Identify and record previous pain history and management of that pain and impact on function. Identify previous response to [MEDICATION NAME] including pain relief, side effects and impact on function; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from the resident’s past experience of pain. Record review of the resident’s nurse progress notes dated 4/02/19, at 9:25 P.M., showed the following: -A nurse notified the pharmacy of the need for the resident’s [MEDICATION NAME] 7.5 mg; -The pharmacy said they sent out the medication on Wednesday and the facility should still |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 47) have a supply for the resident; -The nurse informed the pharmacy, the facility did not have the medication and would need to have the medication refilled; -The pharmacy said the DON would need to call and give authorization of the medication to be sent; -The nurse called the DON and notified of the situation. Record review of the resident’s nurse progress notes dated 4/03/19, at 12:34 A.M., showed the following: -The nurse placed a call to the pharmacy in regards to the medication not available in emergency kit; -The pharmacy said the medication was out for delivery; -Notified the resident of the situation; -Call placed to the physician; -Resident told the nurse to ask the physician for a temporary order for another pain medication because the nurses did so in the past. Record review of the resident’s progress notes dated 4/03/19, at 8:09 A.M., showed a nurse documented the following: -Received a physician’s orders [REDACTED]. for [MEDICATION NAME] 5 mg, give one tablet every four hours as needed for pain, and discontinue this order when the resident’s regular supply of pain medication is available from the pharmacy; -At 6:18 A.M., nurse administered the [MEDICATION NAME] 5 mg for resident complaint of 4 out of 1-10 pain scale. Record review of the resident’s progress notes dated 4/03/19, at 10:56 A.M., showed a nurse documented the following: -The facility restarted the resident’s order for [MEDICATION NAME] 15 mg, give 0.5 tablet (to equal 7.5 mg) and the nurse administered a dose of the medication. During an interview on 4/24/19, at 3:30 P.M., the resident said the following: -The resident states he/she has difficulty getting pain medications when needed; -The resident said at times the facility runs out of pain medications for the residents; -The resident said other times, the nurses are slow to deliver the pain medications; -The resident said he/she frequently waits an hour for pain medication after requesting the medicine. Record review of the resident’s (MONTH) 2019 RN/LPN MAR indicated [REDACTED] -On 4/25/19, at 1:30 A.M., a nurse documented the resident’s pain level as a ‘4’ and administered [MEDICATION NAME] 15 mg, 0.5 tablet; -On 4/25/19 at 5:30 A.M. a nurse documented the resident’s pain level as a ‘4’ and administered [MEDICATION NAME] 15 mg, 0.5 tablet; -Staff did not document administration of any additional doses of [MEDICATION NAME] 15 mg, 0.5 tablet on 4/25/19. Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED] -On 4/25/19, staff documented a pain evaluation at 6:30 A.M., showing the resident’s pain level as a ‘3’; -On 4/25/19, staff did not document any interventions. Record review of the resident’s progress notes dated 4/25/19, at 3:36 P.M., showed LPN X entered the following order: -[MEDICATION NAME]/[MEDICATION NAME] tablet 5/325/ milligrams (mg) give one table every 4 hours as needed for pain use order until [MEDICATION NAME] 7.5 mg arrives from pharmacy then discontinue. Record review of the resident’s care plan, revised on 4/25/19, showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 48) -Resident has potential to have verbally aggressive and manipulative behaviors related to pain management. Examples include keeping narcotics at bedside, becoming tearful when he/she is unable to get his/her wishes, and calling a family member to speak to staff when he/she does not get his/her wishes; -Staff to give the resident as many choices as possible about care and activities; -Provide positive feedback for good behavior. Emphasize the positive aspects of compliance; -Resident will be compliant with physician orders [REDACTED]. During an interview on 4/25/19, at 4:37 P.M., RN K said the following: -The resident has had an issue with pain management and pain control; -A CNA reported that the resident had a bottle of pain pills in his/her room, staff asked the resident about the medications and the resident said admitted to having the medication; -The facility does have an issue with pain medication availability, but when that occurs the nurses put another medication in place; -The resident had a bottle of [MEDICATION NAME] 5/325 mg (20 pills) in his/her dresser with a note dated that family brought the medication into the facility on [DATE]; -The facility does not believe the resident has taken any of the pain pills. During an interview on 4/26/19, at approximately 12:00 P.M., the resident’s family member arrived to the resident’s room and said the following: -He/she did bring the resident a bottle of [MEDICATION NAME] for emergencies to keep in his/her room, but the resident had not taken any of the pills; -The family member said he/she brought the medication to the resident because the facility ran out of the resident’s pain medication and the resident went without medication for 24 hours. 3. During an interview on 4/26/19, at 9:30 A.M., CMT GG, said the following: -For approximately the past month, the facility has had an issue with running out of pain medications for the residents; -The facility is using a different pharmacy a couple months ago and this pharmacy does not send medications timely when staff order the medications; Facility staff call the pharmacy and the pharmacy often gives the excuse they are waiting on the physician’s script; -Residents are in pain and they need their pain medications; -Sometimes the nurses have to call the physicians and get an order for [REDACTED].>-The PRN pain medications are what the facility generally runs out of for the residents. 4. During an interview on 4/26/19, at 10:25 P.M., the Director of Nursing (DON) said the following: -The facility has a new pharmacy provider; -Since the new pharmacy started, the facility has a problem with running out of narcotic pain medications for the residents; -The facility has a problem with getting one of the facility physicians to sign narcotic scripts; -The physician refuses to sign scripts during the day, he will only sign in the evening from his home; -This sometimes results in a delay in the pharmacy sending the resident’s ordered pain medications; -This creates a delay of up to 24 hours at times; -The administrator is aware of the issue with not getting narcotics timely. 5. During an interview on 4/26/19, at 10:55 A.M., the RN K said the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 49) -The RN said the facility has an issue with having pain medications available for the residents; -One of the facility physician will only sign scripts one time per day; -He/she has asked the physician to sign scripts for resident pain medication in the middle of the day, while the physician is in the facility, and the physician refuses; -The nurses also run out of medications to use in the emergency kit or do not have certain medications in the kit; -Some of the staff/residents have reported that nurses tell them the facility does not have their pain medications and they will have to wait; -The RN said she would expect the nurses to treat the resident’s complaints of pain with ordered medications, or by contacting the physician, or by offering non-pharmacological interventions. 6. During an interview on 4/26/19, at 11:20 P. M., CNA HH said the facility has difficulty getting pain medications from the pharmacy, especially for the newly admitted residents. 7. During an interview on 5/07/19, at 1:20 P.M., the medical director said the following: -He expected the facility to have the ordered pain medications available for the residents; -The facility has changed pharmacies three times in the last year and he suspects some of the nursing staff may not be educated on the medication ordering process. 8. During an interview on 5/07/19, at 3:15 P.M., the facility administrator and DON said the following: -They expect medications to be administered as ordered and call physician when needed for change in order. MO 966 and MO 354 | |
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure medication error rates are not 5 percent or greater. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 50) administer those eye drops to the resident; the night shift might give those drops. CMT A washed his/her hands, donned gloves, and instilled one drop of Latanoprost 0.005% solution into each of the resident’s eyes. 2. According to the manufacturer’s guidelines, a [MEDICATION NAME](fast acting insulin) pre-filled pen should be primed with each use by expelling two units of insulin prior to the administration of the ordered units for the dose. Record review of a facility’s policy and procedure entitled Medication Administration – Subcutaneous Insulin, dated (MONTH) (YEAR), showed the following: -Administer subcutaneous (under skin) insulin as ordered and in a safe, accurate and effective manner; -When using a pre-filled insulin pen, always perform the safety test before each injection to ensure that you get an accurate dose: -Set the dose; -Hold the pen with the needle pointing upwards; -Tap the insulin reservoir so that any air bubbles rise up toward the needle -Press the injection button all the way in; check to see if insulin cones out of the needle tip. Repeat if necessary; change needles after three failed tests; -Check that the dose window shows 0 following the safety test. 3. Record of Resident #15’s (MONTH) 2019 POS for (MONTH) 2019 showed an order, dated 3/22/19, for [MEDICATION NAME] Solution (Insulin [MEDICATION NAME]); inject eight units subcutaneously in the afternoon for diabetes. Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED] -[MEDICATION NAME] Solution, 8 units, scheduled for 12:00 P.M. daily. Observation and interview on 5/2/19, at 11:57 A.M., showed CMT B performed an AccuCheck (blood test to determine glucose/sugar level) for the resident. The CMT said the resident had physician orders [REDACTED]. CMT B removed the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a disposable needle. Without priming the insulin pen, CMT B turned the dial on the pen to the 8 indicator mark and administered the insulin to the resident’s upper right arm. 4. Record review of Resident #67’s (MONTH) 2019 POS showed an order, dated 4/19/19, for [MEDICATION NAME] (fast acting insulin) [MEDICATION NAME] Solution Cartridge 100 units/ml (Insulin [MEDICATION NAME]); inject three units subcutaneously with meals related to diabetes. Record review of the resident’s [DATE], showed the following: -[MEDICATION NAME] Solution Cartridge, 3 units, scheduled for 12:00 P.M. daily. Observation and interview on 5/2/19 at 12:12 P.M., showed CMT B performed an AccuCheck for Resident #67. The CMT said resident had physician orders [REDACTED]. CMT B removed the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a disposable needle. Without priming the pen, CMT B turned the dial on the pen to the 3 indicator mark and administered the insulin to the resident’s abdomen. 5. Record review Resident #4’s physician’s orders [REDACTED].>-an order for [REDACTED].>-an order for [REDACTED]. Observation and interview on 5/2/19, at 8:01 A.M., showed CMT R had already performed an AccuCheck for the resident. The CMT said resident had physician orders [REDACTED]. CMT R removed the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a disposable needle. Without priming the pen, CMT R turned the dial on the pen to the 70 indicator mark and administered the insulin to the resident’s abdomen. 6. During an interview on 5/7/19, at 10:35 A.M., CMT L said he/she attended a specialized class pertaining to insulin administration. At the conclusion of the class, he/she took |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 51) both a written and hands-on test to become certified to administer insulin in a nursing facility. CMT L said he/she spent a day or two with CMT B as orientation at this facility and received no instructions pertaining to priming insulin pens. CMT L was unaware of the need to prime an insulin pen. 7. During an interview on 5/7/19, at 10:55 A.M., Licensed Practical Nurse (LPN) M said an insulin pen should be primed before the first use of the pen, but was not aware of recommendations to prime with every use. 8. During an interview on 5/7/19, at 3:16 P.M., the Director of Nursing (DON) said nurses and CMTs should verify that a medication matches the MAR before administering the medication. The DON said insulin pens should be primed with two units prior to every use. 9. During an interview on 5/2/19, at 8:00 A.M., CMT R said he/she has been at the facility approximately 3 months and took a two day class for insulin certification. MO 938, MO 966, MO 354, MO 428 and MO 587 | |
| F 0760 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that residents are free from significant medication errors. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0760 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 52) The CMT said the resident had a physician orders [REDACTED]. CMT B removed the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a disposable needle. Without priming the insulin pen, CMT B turned the dial on the pen to the 8 indicator mark and administered the insulin to the resident’s upper right arm. 2. Record review of the Resident #67’s (MONTH) 2019 POS showed an order, dated 4/19/19, for [MEDICATION NAME] Solution Cartridge 100 units/ml (Insulin [MEDICATION NAME] – rapid acting insulin); inject three units subcutaneously with meals related to diabetes. Record review of the resident’s (MONTH) 2019 MAR indicated [REDACTED] -[MEDICATION NAME] Solution Cartridge, 3 units, scheduled for 12:00 P.M. daily; -Staff documented administration of the [MEDICATION NAME] Solution, 3 units, daily. Observation and interview on 5/2/19, at 12:12 P.M., showed CMT B performed an AccuCheck for the resident. The CMT said the resident had physician orders [REDACTED]. CMT B removed the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a disposable needle. Without priming the pen, CMT B turned the dial on the pen to the 3 indicator mark and administered the insulin to the resident’s abdomen. 3. Record review Resident #4’s physician’s orders [REDACTED].>-an order for [REDACTED].>-an order for [REDACTED]. Observation and interview on 5/2/19, at 8:01 A.M., showed CMT R had already performed an AccuCheck for the resident. The CMT said resident had physician orders [REDACTED]. CMT R removed the cap from the insulin pen, wiped the tip with an alcohol swab, and attached a disposable needle. Without priming the pen, CMT R turned the dial on the pen to the 70 indicator mark and administered the insulin to the resident’s abdomen. 4. During an interview on 5/7/19, at 10:35 A.M., CMT L said he/she attended a specialized class pertaining to insulin administration. At the conclusion of the class, he/she took both a written and hands-on test to become certified to administer insulin in a nursing facility. CMT L said he/she spent a day or two with CMT B as orientation at this facility and received no instructions pertaining to priming insulin pens. CMT L was unaware of the need to prime an insulin pen. 5. During an interview on 5/7/19, at 10:55 A.M., LPN M said an insulin pen should be primed before the first use of the pen, but was not aware of recommendations to prime with every use. 6. During an interview on 5/7/19, at 3:16 P.M., the Director of Nursing (DON) said insulin pens should be primed with two units prior to every use. MO 938, MO 966, MO 354, MO 428 and MO 587 | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 53) NAME]. Certified Medication Technician (CMT) A said staff had borrowed some of the capsules from the stock bottle (used for administration to any resident with a physician order [REDACTED]. During the observation, CMT A said, We probably shouldn’t do that. 2. According to the United States Food and Drug Administration, once opened insulin must not be used after 28 days due to loss of potency and the risk of contamination. According to the United States Pharmacopeia Dispensing Information (USPDI) as well as the United States Food and Drug Administration (FDA), once opened, insulin must not be used after 28 days due to loss of potency and the risk of contamination. Record review of Resident #70’s admission Minimum Data Set (MDS – a federally mandated assessment tool completed by facility staff), dated 3/14/19, showed the following: -admitted to the facility on [DATE] from the hospital; -Cognitively intact; -Resident has [DIAGNOSES REDACTED]. Record review of the resident’s medication review report showed the following current order: -Humalog insulin (rapid action insulin) inject 10 units subcutaneously (SQ) with meals for [DIAGNOSES REDACTED]. Record review of the resident’s electronic Medication Administration Record [REDACTED]. Observation and interview on 05/02/19, at 8:30 A.M., showed the following: -Licensed Practical Nurse (LPN) MM stood outside of the resident’s room and prepared to administer insulin to the resident; -The nurse initially pulled a vial of [MEDICATION NAME] (long [MEDICATION NAME] insulin) from the medication cart and then realized his/her mistake and replaced the [MEDICATION NAME] into the cart and removed a vial of Humalog insulin from a box labeled with the resident’s information on a prescription label; -The nurse cleaned the top of the vial with an alcohol wipe and using an insulin syringe to withdraw 10 units of Humalog insulin from the vial; -The Humalog insulin vial did not have a date on the vial as to when staff opened the vial; -The nurse looked on the vial and on the box and said he/she could not find a date when opened; -The nurse entered the resident’s room cleaned the resident’s left upper arm with alcohol and administered the insulin into the resident’s left upper arm. During an interview on 5/06/19, at 3:55 P.M., the Registered Nurse/Unit Manager (RN) K said the following: -When a nurse opens a new vial of insulin that nurse is responsible for dating and initialing the vial; -The insulin is considered good for 28 days after opening, insulin dated older than 28 days should be discarded and replaced with a new vial; -If an open vial of insulin is not dated when opened, that vial should be discarded and replaced with a new vial of insulin. During an interview on 5/07/19, at 3:15 P.M., the Director of Nursing (DON) said the following: -Nurses should date insulin when a new vial is opened; -Insulin vials should be discarded 28 days after opening; -Nurses should not administer insulin from an undated vial. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | ||
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Based on observation, interview, and record review, the facility failed to serve residents |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 55) -The puree white fish was mechanical consistency, as it had small chucks; -The snap peas had a slick texture and had a mushy consistency. During an interview on 04/25/19, at 10:53 A.M., Resident #57 said the food is bland and often it consists of only starchy foods. During an interview on 04/30/19, at 10:58 A.M., DA E said he/she follows the puree recipes. He/she always adds thickener to the purees. During an interview on 05/07/19, at 1:49 P.M., the Dietary Manager (DM) said staff are to follow the recipe when preparing puree meals. Staff can add thickeners if there is an inconsistency issue, however they should not add it if not necessary. Puree meals should have a smooth consistency. The DM said she tastes the food prior to it being served to ensure quality. During an interview on 05/07/19, at 3:19 P.M., the Administrator said the food should look appetizing and taste good. MO 938 and MO 354 | |
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 56) side of the body) and stroke diagnoses; -Resident requires extensive assistant by one staff to eat, aspiration risk; -Resident has a communication problem related to [MEDICAL CONDITION] (an impairment of language, affecting the production or comprehension of speech and the ability to read or write); -Staff to anticipate and meet needs; -Resident is able to nod head yes or no; -The care plan did not address a meal preference for the resident. Record review of the resident’s admission nurse note dated 4/12/19, at 9:11 A.M., showed the following: -Late entry for 4/11/19 at 11:40 P.M.; -Resident arrived from the hospital; -admission orders [REDACTED] -Resident is non-verbal, but is able to follow conversation and make needs known by nodding or shaking head. Record review of the resident’s activity progress note dated 4/12/19, at 12:22 P.M., showed the activity assistant documented the following: -Resident only able to answer yes and no to the questions asked; -Resident enjoys music, being outside, puzzles, reading, religion, television, due to his/her inability to speak, it is unknown what exact things the resident is into. Record review of the resident’s admission minimum data set (MDS – a federally mandated assessment tool completed by facility staff), dated 4/18/19, showed the following: -Severe cognitive impairment; -Disorganized thinking, behavior present, fluctuates (comes and goes); -Very important to the resident to participate in religious practices; -[DIAGNOSES REDACTED]. -Resident has feeding tube and consumes mechanically altered diet for nutritional needs; -Receives physical therapy (PT), occupational therapy (OT), and speech therapy (ST), five times per week each. Record review of the resident’s social service admission note dated 4/18/19, at 3:49 P.M., showed the following: -Severe cognitive impairment; -No depression; -Resident is his/her own responsible party; -Resident expressed that his/her discharge plan is to go back home with family; -The note did not address any religious preference of the resident. Record review of the resident’s nutritional assessment, dated 4/18/19, completed by the dietitian, showed the following: -Mechanical soft diet; -Glucerna (a high calorie nutritional formula) 1.5 calorie at 60 ml/hour (hr) until 1200 milliliters (ml) infused with 60 ml/hr autoflush; -No known food allergy; -Monitor intake; -The assessment did not address any religious preferences. Record review of the resident’s social services evaluation, dated 4/18/19, showed the following: -Religious/cultural/hobbies section left blank; -Staff failed to answer questions about the resident’s religious affiliation/church, cultural/spiritual influences, medical sanctions or restrictions, or what faith traditions |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 57) are important to the resident. Record review of the resident’s care plan, revised on 4/25/19, showed the resident’s religion is non-denominational. Observation on 4/30/19, at 1:20 P.M., showed the following: -The resident had a meal of a slice of plain bread an unopened tub of butter, buttered pasta with no sauce, and ground meat with stewed chunks on the meat, the resident had a glass of lemonade to drink; -The resident did not eat the ground meat. Observation and interview on 5/01/19, at 1:15 P.M., showed the following: -The resident lay in bed with a lunch tray on the over bed table across the resident’s bed; -The resident ate stuffing covered with gravy and a dry roll, the resident pointed to the meat and asked what it was. When told the meat was pork roast, the resident shoved the entire over table away from the bed and frowned; -The resident indicated he/she did not like pork because of religious reasons; -The resident indicated no staff had asked the resident about his/her food preferences. During an interview on 5/02/19, at 10:45 A.M., Registered Nurse/Unit Manager (RN) K said he/she did not know if the dietitian ever saw the resident. During an interview on 5/02/19, at 11:24 A.M., the Director of Nursing (DON) said if a resident needs a new diet ordered, the DON or a nurse would contact the physician. During an interview on 5/02/19, at 12:30 P.M., the Dietary Manager (DM) said the following: -The facility previously had a full time RD, who left in (MONTH) 2019; -Since the beginning of the year, the dietitian charts remotely on the residents; -The DM said she has seen the RD one time in the facility; -The DM said she attempted to talk with the resident about his/her food preferences, but the resident has a communication problem; -The DM was unaware of any special dietary needs/religious preferences/restrictions; -The DM said he/she has not attempted to contact the resident’s family to discuss the resident’s preferences. During an interview on 5/02/19, at 2:00 P.M., a family member of the resident said the following: -Another family member tried to talk with different facility staff about not giving the resident pork, but the resident is still being served pork; -The family member said the resident does not eat pork for religious reasons. During an interview on 5/07/19, at 8:20 A.M., Speech Therapist (ST) JJ, said the resident refused to eat bacon in the past, but the ST was unsure of the reason. During an interview on 5/07/19, at 8:35 A.M., the Social Service Coordinator (SSC) said the SSC has not spoken with the resident’s family and was unaware of any religious/food preferences. During an interview on 5/07/19, at 9:32 A.M., the Activity Director (AD) said the following: -On the resident’s initial activity assessment completed by the activity assistant, the resident indicated that his/he religious preference was non-denominational; -Today, the resident is indicating he/she is kosher, so the AD will notify dietary. During an interview on 5/07/19, at 11:05 P.M., the DON said the DON said the admissions coordinator and the activity department are responsible for determining resident food preferences and religious restrictions. During an interview on 5/07/19, at 1:15 P.M., the admissions nurse said the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0806 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 58) -He/she visited with the resident on admission, but the resident was non-verbal, so he/she had no way of finding out the resident’s religious preferences; -He/she documented unknown on the resident’s religion; -He/ she never got an opportunity to contact the resident’s family. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to serve food |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 59) -DA E left the kitchen and returned. The DA did not perform hand hygiene and reapplied gloves; -DA F put on gloves, no hand hygiene observed; -DA F touched bread and cheese with gloved hands and placed sandwiches in a bin; -DA F went into dry storage with gloved hands to get a new loaf of bread, removed twist tie, and continued making sandwiches; -DA F placed the bin of sandwiches in the walk-in refrigerator while still wearing gloves; -DA F then directly touched cheese and wrapped in saran wrap with the same gloved hands; -DA E put on gloves without performing hand hygiene. He/she started to puree vegetables; -DA E directly touched bread with gloved hands; -DA E took off his/her gloves and touched the trashcan lid with bare hands. The DA did not perform hand hygiene; -DA E wrapped a steam tray with saran wrap and then retrieved clean serving utensils; -DA F put on a pair of gloves without performing hand hygiene. DA F removed sandwiches from the fridge, moved carts, rearranging bins, took off glasses and put back on, and then got ice. DA F removed gloves and put on a new pair without performing hand hygiene. He/she then touched bread. -DA F removed pudding from walk-in refrigerator with gloved hands. He/she then placed bread on resident’s plates, while also touching individual butter cups, hall tray carts, and the sandwich bin; -DA F went in walk-in refrigerator to a get salad. He/she did not removed their gloves and continued placing bread on resident’s plates; -DA E served food onto resident’s plates with gloved hands. He/she touched lids, utensils other staff had touch, and directly touched noodles on a resident’s plate; -DA F closed up hall cart with his/her gloved hands. He/she pushed the cart out of the way and pulled over a new cart. He/she then put a new pair of gloves over her existing pair. He/she continued to place bread on resident’s plates. -DA F entered the walk-in refrigerator with gloved hands, got fruit plate, and then directly touched a grilled cheese sandwich; -DM put on gloves without performing hand hygiene. The DM pushed drink cart, got a pair of scissors, went into dry storage, directly touched hot dog buns, and then proceeded to roll silverware in napkins; -DA F went into the walk-in refrigerator with gloved hands and retrieved hot dogs; -DA E while wearing gloves, took the hot dogs over to prep area and wrapped in saran wrap. He/she removed gloves, put the hot dogs in walk-in refrigerator. He/she put on new gloves wihtout performing hand hygiene; -DA F still wearing the same gloves, cut up hot dog buns, then pulled up room tray cart. He/she then touched bread and a grilled cheese sandwich. Observation of the kitchen on 05/01/19, at 1:35 P.M., showed DA F wearing gloves. He/she placed rolls on resident’s plates with his/her gloved hands. He/she then touch a hall tray cart and then placed a second pair of gloves over his/her existing gloves. During an interview on 05/07/19, at 11:26 A.M., DA E said he/she will wash hands before serve out and will do again when changing tasks. He/she will wash hands between each use if wearing gloves. During an interview on 05/07/19, at 1:51 P.M., the DM said staff are to wear gloves when handling ready to eat food. Staff must change gloves and wash hands when changing tasks. Staff need to wash their hands when they enter the kitchen and before putting on gloves. Staff should not put on two pairs of gloves. During an interview on 05/07/19, at 11:35 A.M., DA F said he/she washes hands and puts on |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 60) a fresh pair gloves frequently. He/she will put on gloves over top of old gloves. Everyone working in the kitchen needs hair net. 3. Record review of the 2013 Missouri Food Code showed the following information: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Observation of the kitchen on 04/30/19, starting at 11:00 A.M., showed DA G in the kitchen without a hair net. Observation of the kitchen on 05/01/19, at 1:40 P.M., showed DA G in the kitchen without a hair net. Observation of the kitchen on 05/03/19, at 1:30 P.M., showed DA G in the kitchen without a hair net. Observation of the kitchen on 05/07/19, at 11:00 A.M., showed DA G in the kitchen without a hair net. During an interview on 05/07/19, at 11:26 A.M., DA E said anyone working in the kitchen must have a hair net. During an interview on 05/07/19, at 1:51 P.M., the DM said staff must wear hair nets. During an interview on 05/07/19, at 11:35 A.M., DA F said everyone working in the kitchen needs hair net. 4. Observation on 05/07/19, at 11:30 A.M., showed the following: -A food refrigerator used for resident foods had multiple dried sticky fluid spills on the shelving and on the floor of the refrigerator which were brown and yellow in color. During an interview on 5/07/19, at 11:45 A.M., Licensed Practical Nurse (LPN) M said the night shift nursing staff are responsible for cleaning resident food refrigerator. During an interview on 5/07/19, at 11:50 A.M., the Director of Nursing (DON) said the following: -Nursing staff (no specific staff member designated) is responsible for cleaning the resident food refrigerators in the medication room; -The DON said she did not have a cleaning schedule for the refrigerator. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/25/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265188 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SPRING VALLEY HEALTH & REHABILITATION CENTER | STREET ADDRESS, CITY, STATE, ZIP 2915 SOUTH FREMONT AVE | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 61) resident’s room. CMT R returned to the medication cart and placed the glucometer on top of the cart. CMT R retrieved an alcohol swab from the cart, wiped off the machine for less than 10 seconds, and then placed the glucometer directly back into a box inside the right bottom draw in the contaminated medication cart. 2. During an observation and interview on 5/2/19, at 8:12 A.M., showed CMT A performed an AccuCheck for Resident #89 in the resident’s room. CMT A returned to the medication cart and placed the glucometer on top of the cart. The CMT said he/she didn’t know what other staff did, but he/she thought the machine should be cleaned between uses. CMT A retrieved a Microkill disinfectant wipe, wiped off the machine for less than 10 seconds, and then placed the glucometer directly back on the top of the contaminated medication cart. 3. During an interview on 5/7/19, at 10:35 A.M., CMT L said he/she used an alcohol swab to wipe off the glucometer before and after use. He/she said another CMT spent a day or two oriented him/her upon hire. 4. During an interview on 5/7/9, at 3:16 P.M, with the Administrator and the Director of Nursing (DON), the DON said staff should use a Microkill wipe to clean off a glucometer after use. The machine should then be placed on a barrier cloth to air dry for at least two minutes. MO 428 | |
| F 0921 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to maintain a clean medication | |
