Goldwater Care Spring Valley

Inspectors wroteBased on observation, interview, and record review the facility failed to offer substitutes/alternatives for meals of equal nutritional value. This applies to 3 of 3 residents (R9, R10, R11) reviewed for substitutes in the sample 11.

Inspectors wroteBased on interview and record review the facility failed to ensure resident's records were complete and accurate for1 of 3 residents (R1) reviewed for accuracy of medical records in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to identify, monitor, and review prophylactic antibiotic use for five (R1, R2, R33, R54, and R67) of five residents reviewed for antibiotic stewardship in the sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident's range of motion quarterly, and failed to implement and follow through ROM (Range of Motion) exercises for one of two residents (R2), a resident with functional limited range of motion, in the sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall precautions for one of five residents (R43), reviewed for falls in a sample of 36. The facility policy, Fall Prevention Program, dated (revised) 11/21/17 directs staff, To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The fall prevention program includes the following components: Methods to identify residents at risk, communication with direct staff members. Safety interventions will be implemented for each resident identified at risk. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform urinary catheter care to reduce the risk of infection for one of two residents (R221) reviewed for urinary catheters, in a sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to document a rationale for the continued use of an antibiotic for one of two residents (R2), reviewed for unnecessary medications in a sample of 36. Findings Include: The facility policy, Antibiotic/Antimicrobial Stewardship Program, dated 11/28/2017 directs staff, This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program will help ensure that our residents get the right antibiotics at the right time for the right duration, and can help improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections and reduce healthcare costs. This facility utilizes the McGeer's Criteria for determining if an infection meets criteria for treatment with an antibiotic. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene during medication administration for one of two residents (R48) reviewed for medication administration, in a sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident safety during transfer, failed to use a gait belt during resident transfer, and failed to follow the facility policy and procedure for mechanical lift slings for one (R4) of three residents reviewed for falls in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice scoop, for the ice machine, was stored on the outside of the ice machine. This failure has the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lids, to the trash receptacle, were closed and the area surrounding the trash receptacle was free of litter. This failure has the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a Comprehensive Care Plan for three residents (R8, R24, and R35) of 29 residents reviewed for Care Plans in a sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise a plan of care for two (R27 and R49) of 29 residents reviewed for care planning in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed obtain a physician order for a weight loss program and to ensure a resident with significant weight loss was monitored and followed by a physician for one (R8) of three residents reviewed for weight loss in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a PEG (percutaneous endoscopic gastrostomy) tube dressing change was completed as physician ordered for one (R27) of one resident reviewed for tube feeding in the sample of 29.

Inspectors wroteBased on observation, interview and record review the Facility failed to clean, maintain and change disposable Respiratory supplies for two of three Residents (R52 and R71) reviewed for Respiratory Care in a sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician treatment order for one resident (R1) reviewed for wound treatment orders in a sample of three. Findings Include: The facility's Pressure Injury and Skin Condition Assessment Policy, dated 1/17/18, documents: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries, and other ulcers and assuring interventions are implemented. 18. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. R1's diagnoses include: Personal history of other malignant neoplasm of skin, varicose veins of right and left lower extremities, non-pressure ulcer of right and left lower extremities, excoriation (skin picking) disorder, end stage renal disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure current daily nurse staffing information was posted, and 18 months of nurse staffing postings were maintained. This failure has the potential to affect all 75 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a dietary manager on a full-time basis, and ensure all dietary staff withheld a food handler's certification. This has the potential to affect all 75 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at an appropriate temperature to prevent pathogenic microorganisms that may cause foodborne illness, maintain safe food temperatures of food being held on the steam table, monitor food temperatures, use a sanitizing solution to sanitize the high contact surfaces of the kitchen and dining room tables, monitor the sanitizer levels prior to cleaning surfaces, and maintain clean air vents in the kitchen. This has the potential to affect all 75 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to wear appropriate PPE (Personal Protective Equipment) while in COVID-19 positive resident rooms, failed to remove/disinfect contaminated PPE upon exit from COVID-19 positive resident rooms and prior to traveling throughout the facility for one resident (R71) and failed to wear proper PPE while handling COVID-19 positive resident laundry during laundry services, during a facility-wide COVID-19 outbreak. The facility also failed to apply the required PPE prior to resident COVID-19 testing and perform hand hygiene after removing gloves for three residents (R26, R64, R67). These failures have the potential to affect all 75 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve pureed food according to the facility's menu for three of three residents (R4, R28, R31) reviewed for pureed diets in the sample of 40.