Eden Valley Care Center

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to ensure a Registered Nurse (RN) provided services eight consecutive hours, seven days a week in the facility for 5 of 28 days reviewed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure as-needed (PRN; pro re nata) orders for psychotropic drugs were limited to 14 days without documented rationale for 1 (Resident #9) of 5 residents reviewed for unnecessary medications. Specifically, Resident #9 had an order for hydroxyzine hydrochloric acid (HCl) (an antianxiety medication) started on 12/29/2024, with no stop date or documented rationale for continued use.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) for 1 (Resident #41) of 2 residents reviewed for urinary catheters.

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Set (MDS - a resident clinical assessment tool) assessments within the required time frame for two of 51 residents (Resident 1 and 2). This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Set (MDS - a resident clinical assessment tool) assessments within the required time frame for two of 51 residents (Resident 1 and 2). This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans and update these care plans for two of 51 Residents (Resident 1 and 2) in accordance with the Minimum Data Set (MDS - a resident clinical assessment tool) assessments required time frame. This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a lifesaving technique consisting of chest compressions and often combined with artificial ventilation used in emergencies to treat persons with ineffective heart pumping/beating and compromised breathing to improve blood perfusion throughout the circulatory system to vital organs, especially to the brain) for one of 2 sampled Residents (Resident 1) when Resident 1 was found unresponsive. This failure left Resident 1 without receiving (CPR), which was not in accordance with his choice for full treatment (to prolong life by all medically effective means), as indicated in his POLST (Physician Orders for Life-Sustaining Treatment).

Inspectors wroteBased on interview and record review, the facility failed to safely discharge on e of three residents (Resident 1) when Resident 1 was discharged , due to non-payment, while the facility's business office actively sought a payor source for Resident 1's stay in the facility and when the resident's Medi-Cal (California's health care program which covers most medically necessary care) eligibility was pending. Resident 1 cried because she did not want to be discharged and was being discharged to a shelter against her wishes. Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her, and Resident 1 returned to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm was not followed-up prior to discharge; 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a discharge notice 30 days prior to discharge for one of three residents (Resident 1) when: 1. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a shelter. 2. The Office of the State Long-Term Care Ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) did not receive a discharge notice 30 days prior to the resident ' s discharge. This failure resulted in Resident 1 not receiving sufficient notice prior to her discharge to prepare her post discharge care.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the Preadmission Screening and Resident Review (PASRR, a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care; Level I Screening is a tool to identify individuals who are diagnosed or suspected to have MI, DD, or ID; based on the Level II Evaluation, as performed by the State-Designated Authority [SDA] when Level I screening showed the individual is positive for MI, the Department of Health Services would issue a determination of the treatment and placement recommended for the individual) assessments for one of three residents (Resident 1) when: 1. Resident 1's PASSR was not completed prior to admission or within 30 days of admission; and, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary treatment and services for one of three residents (Resident 1) prior to discharge when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm were not evaluated prior to her discharge. 4. [...]

Inspectors wroteBased on interview, record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 1) when the Attending Physician (AP) and Responsible Party (RP, person designated to make decisions on behalf of a resident) were not notified after Resident 1 got out of the facility unassisted. This failure resulted in Resident 1's RP and Attending Physician being left unaware of the resident's elopment status.

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Set (MDS, an assessment tool) assessments timely for five residents (Residents 2, 3, 4, 5, and 6). This failure had the potential to result in inadequate care based on delayed assessments and care planning.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse (RN) signed and certified that Minimum Data Set (MDS, an assessment tool) assessments were completed when: 1. The MDS Coordinator (MDSC), a licensed vocational nurse, falsified the dates and signatures for three MDS assessments for Residents 2, 3, and 4. 2. The Medical Director signed Resident 1's MDS assessment when there was no RN available. These failures had a potential to result in inaccurate assessments that could affect the plan of care and delivery of necessary care and services for residents.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary treatment when there was no registered nurse available on 2/4/23, 2/5/23, and 2/9/23 to administer intravenous (IV, to deliver a medication into a vein) antibiotic (medication used to treat bacterial infections) medication for Resident 1. This failure resulted in three missed IV antibiotic doses for Resident 1. This failure had the potential to compromise the resident's health and result in ineffective antibiotic therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for 10 of 12 sampled residents when: 1. For Resident 9 and 21 pacemakers were not monitored; 2. For Resident 230, her oxygen inhalation order was not followed; 3. For Resident 14, the nursing staff did not carry out the physician's order for labs; 4. For Residents 14, 15, 26, 128, 12, 22, 25 and also 230, staff did not document the systolic blood pressure (amount of pressure in the arteries during the contraction of the heart muscle) between lying and/or standing/siting positions when completing the Fall Risk Evaluation. Accuracy of assessments is important in identifying the resident-centered needs and appropriate interventions of each resident. Resident Assessments are the bases of resident's plan of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared and served under safe and sanitary conditions when: 1. six aluminum baking pans were rusty; and 2. food trays were stored underneath the dishwashing sink beside chemicals. These failures had the potential for foodborne illness (caused by food or water contaminated with bacteria, viruses, parasites or toxins) for the 33 residents receiving food from the kitchen.

Inspectors wrote2. During medication administration observation for Resident 5 on 10/3/22 at 9:15 a.m., LVN H was observed donning on a pair of gloves, then turning off the G-tube feeding by touching the feeding pump. LVN H touched the bed remote control to raise the bed and disconnected the G-tube. Then LVN H flushed the G-tube with water and proceeded with the medication administration without changing gloves and washing hands after touched potentially contaminated surfaces. During an interview with LVN H on 1/3/22 at 10:15 a.m., the LVN H stated, I should remove gloves, wash my hands, and apply new pair of gloves after I touched the bed remote control, G-Tube, and pump. I should do hand hygiene before I started flushing water and medications via GT. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the dignity for one of 12 sampled residents (Resident 14) when provide privacy that exposed her thighs and incontinent pads to public view. This failure violated Resident 14's right to dignity and privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a licensed nurse transcribed and carried out a physician's telephone order to use resident's own eye drops and apply as ordered; and, for the interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) to assess resident's ability to safely keep medication at the bedside and/or administer if able, for one of 12 sampled residents (Resident 128). These failures deprived Resident 128 to have a choice or preference to either keep and/or administer her medications at bedside.

Inspectors wroteBased on interview and record review the facility failed to complete the required annual comprehensive assessments for one of 12 sampled Residents (Resident 15). Assessments are the bases for resident's plan of care and interventions that would address their individualized and resident-centered needs.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for three of 12 sampled residents (Resident 3, 14, 128). 1. Resident 14. had no care plan for risk for wandering/elopement. 2. Resident 128, had no person centered and individualized care plan developed for bowel and balder program. 2. Resident 3, had no care plan for depression. This failure may delay the implementation of the interventions, and identification of specific care areas and services necessary to meet the residents' needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, necessary and proper care and services were provided to 3 (Residents 22, 235 and 128) out of 12 sampled residents when: 1. Staff did not monitor Residents 22 and 235 after their altercation incident; and 2. Staff did not apply Resident 128's left arm sling correctly. These failures had the potential to compromise the residents' health and safety.

Inspectors wroteBased on observation, interview and record review the facility failed to carry out physician's orders to help prevent the worsening of existing pressure ulcer (PU, the breakdown of skin integrity due to pressure. which can occur when a bony prominence is under persistent contact with an external surface) for one of 12 sampled residents (Resident 14); and, the facility failed to implement interventions to help prevent the development of pressure ulcers for two of 12 sampled residents (Resident 128 and 232). These failures could potentially result in the development or delayed healing of resident's pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide a restorative nurse assistant (RNA) program (nursing intervention to assist or promote resident's ability to attain their maximum functional potential) for one of 12 sampled residents (Resident 26). This failure had the potential to compromise the residents' ability to attain her maximum functional potential and may result in a decline of resident's health.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision to prevent one of twelve sampled residents (Resident 15) from leaving the facility without staff's knowledge and permission when: 1. Staff did not provide the required assistance and supervision when Resident 15 walked off the unit. 2. Staff did not complete the annual and post wandering incident Wandering Risk Assesment required . The annual assessment was due on May 9, 2022, and the post wandering or elopement episode was due May 22, 2022. The Wandering assessment done on 8/9/22 was inaccurate. 3. Staff did not update/revise/personalized Resident 15's Wanderguard care plan (wanderguard, a device applied to resident's body designed to support caregivers, with simple keypad commands, the option for door bypass using keypads that helps prevent elopement) for elopement/wandering. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (G-tube, a tube surgically inserted into the stomach through the abdomen wall incision for administration of food, fluids, and medications) placement was checked prior to administering medications and water for one of one sampled resident (Resident 5). This failure had the potential to compromise Resident 5's care and could cause health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 14) was free from unnecessary psychotropic medication (drug that affects brain activities associated with mental processes and behaviors). Resident 14 had been receiving olanzapine (Zyprexa, an antipsychotic medication) since 11/5/20: 1. Without adequate side effect monitoring; 2. Without every 6-month monitoring for AIMS (a rating scale designed to measure involuntary movements known as tardive dyskinesia, a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications); and 3. Without attempted gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure education on the risks and benefits of vaccine for COVID-19 (corona virus-illness caused by a virus that can be transmitted from person to person) was provided to the residents/ or responsible party (RP) for three of 12 sampled residents (Resident 9,10,23). This failure resulted in the residents' responsible parties not to have the opportunity to accept or refuse a COVID-19 vaccine for the three residents or for themselves.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the emergency medication supply kit (E-Kit) was replaced according to regulatory time frame. This failure could affect residents' care and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff (DS) utilized standardized recipes for liquefied texture food preparation to ensure nutritive value, which had the potential to place one of two residents (Resident 20) at risk for nutritional impairment.