Cypress Valley Center for Nursing and Rehabilitati

Inspectors wroteBased on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 3 of 92 days reviewed for staffing (11/10/24,11/30/24, and 12/01/24).

Inspectors wroteBased on observations and interviews with the facility staff and the Regional Director of Dietary Services, the facility failed to: 1) Label, date, and seal food items stored in the Dietary Department's walk-in cooler, dry food storage room, and walk-in freezer; 2) Dispose of expired food items observed in food storage areas; 3) Store food products in accordance with the manufacturer's storage instructions; 4) Cover facial hair for 2 of 2 Dietary staff observed with facial hair and working in food preparation (Dietary Manager and Dietary Aide #1); and 5) Keep the kitchen food service equipment clean within the Dietary Department. These practices had the potential to affect food being served to residents.

Inspectors wroteBased on staff interviews, facility and hospital record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of: 1) Preadmission Screening and Resident Review (PASRR) Level II status (Resident #80); 2) Impairment of range of motion (Resident #25); 3) Use of an antibiotic medication (Resident #76); and 4) The residents' discharge location prior to his/her admission to the facility (Resident #52). This occurred for 4 of 21 residents whose MDS assessments were reviewed.

Inspectors wroteBased on observations, record reviews, and resident, resident representative, and staff interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse when Resident #28 hit Resident #98 on the left of his forehead with his fist when Resident #28 tried to exit his room in his wheelchair and was blocked by Resident #98's geriatric reclining chair (geri-chair, a reclining chair used to support individuals with limited mobility). Resident #98 had a raised red area on the left of his forehead after the incident. This deficient practice affected 1 of 4 residents reviewed for abuse (Resident #98).

Inspectors wroteBased on record reviews, and resident and staff interviews the facility's Interdisciplinary Team (IDT) failed to review the care plans after residents' annual and quarterly Minimum Data Set (MDS) assessments and failed to involve residents and/or resident representatives in the care planning process for 2 of 2 sampled residents reviewed for care plan revision and participation (Resident # 80 and Resident #16).

Inspectors wroteBased on observations, records review, and staff interviews, the facility failed to apply a left-hand splint for 1 of 1 resident (Resident #25) reviewed for contractures.

Inspectors wroteBased on staff interview, family interview and record review, the facility failed to clean and maintain resident rooms for 3 of 3 halls (Rooms A11, A15, A17, A19, A20, A21, A22, A25, B16, C12, C26) observed for cleanliness.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage on 14 of 123 days reviewed.

Inspectors wroteBased on observations and staff interviews, the facility failed to date opened multi-dose insulin pen injections in 2 of 4 medication administration carts (Lower A hall and Lower B hall), failed to remove an expired multi-dose insulin pen injections in 1 of 4 medication administration carts (Lower A hall), and failed to discard loose pills in the medication administration cart drawer for 3 of 4 medication administration carts (Lower A hall, Upper and Lower B halls). Findings Included: 1. a. On 6/17/24 at 11:10 AM, an observation of the medication administration Lower A hall cart with Nurse #2 revealed one opened and undated multi-dose Lantus Glargine insulin pen injector, one opened Semglee Glargine insulin pen injector, one opened Humalog Lispro insulin pen injector, and one opened Basaglar insulin pen injector. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to discard expired foods and label and date foods placed in the reach-in refrigerator, walk-in refrigerator and in the dry storage area. The facility failed to maintain the stove's backsplash, side of the stove, oven, deep fryer clean and free of grease, and failed to maintain the silverware holder containing clean silverware free of dried food. The facility failed to maintain the floors of the walk-in refrigerator, walk-in freezer and dry storage clean and free of dirt. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure the handrails in the facility corridors were properly secured to the walls, repaired and free from sharp edges on 3 of 3 halls where handrails were present.

Inspectors wroteBased on record review, family interview and staff interviews, the facility failed to implement an effective discharge planning process for 1 of 1 resident reviewed for discharge to the community (Resident #100).

Inspectors wroteBased on record review and staff interview, the facility failed to complete a recapitulation of stay for 1 of 1 closed record reviewed for discharge to the community(Resident #100).

Inspectors wroteBased on staff interviews, and record review the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of cognitive patterns, and medication for 2 of 2 residents reviewed for resident assessment (Resident #251 and Resident #38).

Inspectors wroteBased on record review and resident, family, staff, and dialysis staff interviews, the facility failed to maintain a resident's dignity by failing to pick up Resident #3 from a dialysis appointment which resulted in the resident feeling terribly upset and angry for 1 of 1 sampled resident reviewed for dialysis (Resident # 3).

Inspectors wroteBased on observations, record review, and family and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 4 residents reviewed for physical abuse (Resident # 10).

Inspectors wroteBased on medical record review, observation and staff interview the facility failed to ensure a resident's urinary catheter bag was positioned below the bladder and secured in a manner to keep it from laying on the floor rather for 1 of 1 sampled resident with a urinary catheter (Resident #10).

Inspectors wrote2. Resident #41 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #41 was cognitively intact and was able to understand others. Resident #41 had adequate vision and required extensive assistance with one-person physical assist for toilet use. On 4/19/23 at 9:11 am an observation was made of Resident #41's call light on. At 9:14 am the Activity Coordinator entered the room and asked the Resident what she needed. Resident #41 informed Activity Coordinator she needed to be changed and stated she had asked to be changed before breakfast. The Activity Coordinator left the room and stated she was going to get materials to change the Resident's brief. [...]

Inspectors wroteBased on observations, and staff interviews the facility failed to maintain a clean oven, conveyor toaster and stove. The facility also failed to maintain clean nourishment room refrigerators, label and date food for 1 of 1 nourishment refrigerators reviewed (A hallway nourishment room). The dietary aide failed to change gloves during dishwashing while handling dirty and clean dishes when observed during dishwashing process. The facility failed to ensure the commercial dishwasher was maintaining the rinse temperatures according to the manufacturer's recommendations. These practices had the potential to affect food being served to residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to clean and maintain the floors, walls, ceiling, window sills/trim, and the exterior surfaces of the PTAC units (individual heating and air conditioning units) and tray tables in the resident rooms in good repair on 3 of 3 hallways observed (C Hallway, A Hallway and B Hallway).

Inspectors wroteBased on staff and resident interviews, observations and record review, the facility failed to provide dependent residents assistance with incontinence care (Resident #s 30 and 41), showers and hair wash (Resident #21), nail care (Resident #80), and empty the urinal (Resident #3) for 5 of 9 residents reviewed for activities of daily living.

Inspectors wroteBased on observations, staff interviews, and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint survey in December 2021 and subsequently recited in April 2023 on the current recertification and complaint survey. The recited deficiency was in the area of food safety requirements and store, prepare, distribute and serve food in accordance with professional standards for food service safety. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program.

Inspectors wroteBased on observations, resident and staff interviews, and record review the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of dental for 1 of 4 residents reviewed for resident assessments (Resident #84).

Inspectors wroteBased on staff interview, observation and record review, the facility failed to provide humidified oxygen as ordered for 1 of 1 resident reviewed for respiratory care (Resident #21).

Inspectors wroteBased on record review and interviews with residents and staff, the facility failed to provide sufficient nursing staff to meet the needs of two of six sampled dependent residents. Resident #30 reported he remained in a stool soiled brief for more than two hours. Resident #3 reported there were not enough staff to answer call lights and assist.

Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to: 1) Store medications in accordance with the manufacturer's storage instructions; and 2) Discard a single-use vial of sterile water after opening. This occurred for 1 of 2 medication carts observed (Upper B Hall Medication Cart).

Inspectors wroteBased on staff interviews, observation, and record review, the facility failed to don personal protective equipment (PPE) before providing care to a resident with ESBL (extended-spectrum beta-lactamases) urine infection (Resident #7) for 1 of 2 residents reviewed for contact precautions.