Mill Valley Care Center

Inspectors wroteBased on observation, record review, staff interview, and policy review the facility failed to follow appropriate transfer techniques resulting in injury for 1 of 1 resident reviewed (Resident #184). The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to document Weekly Pressure Ulcer Assessments for 2 of 3 residents reviewed with pressure ulcers (Residents #2 and #3). The pressure ulcers for these 2 residents worsened during the missed assessment. The facility reported a census of 34. The Minimum Data Set (MDS) Assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. [...]

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to maintain dignity for two of fourteen residents reviewed (Residents #8 and #12). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #12 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and had the following diagnoses: Anemia, Hyponatremia and Malnutrition. The MDS identified the resident required extensive staff assistance with most activities of daily living and totally dependent on staff for locomotion on and off the unit and documented the resident as continent of bladder and bowel. In an interview on 5/15/23 at 10:15 AM, as Resident #12 laid in her recliner, she reported some staff will answer her call light right away and some will not. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to complete a significant change MDS (Minimum Data Set) within 14 days after the resident experienced a significant weight loss for one of two residents reviewed (Resident #20). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #20 as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15 and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease and Non-Alzheimer's Dementia. The MDS identified the resident required extensive staff assistance with transfers, locomotion on the unit, dressing, toileting, personal hygiene and bathing. Resident #20 totally dependent on staff for locomotion off the unit. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to develop a Comprehensive Care Plan to address the indwelling catheter the resident had for one of one residents reviewed (Resident #83). The facility reported a census of 35 residents. Findings Include: 1. The resident did not have a completed Minimum Data Set during the survey. The Electronic Medical Record revealed an admission Date of 5/8/23 and identified the following diagnoses for Resident #83: spinal stenosis, benign prostatic hyperplasia (BPH) and overflow incontinence. On 5/9/23 the Care Plan identified the resident with the only problem of involved in activities of choice and did not address the indwelling catheter. [...]

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to revise a Care Plan with significant weight loss interventions for one of two residents reviewed for Care Plans (Resident #20). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #20 as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15 and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), coronary artery disease and Non-Alzheimer's Dementia. The MDS identified the resident required extensive staff assistance with transfers, locomotion on the unit, dressing, toileting, personal hygiene and bathing. Resident #20 totally dependent on staff for locomotion off the unit. [...]

Inspectors wroteBased on observation, record review and staff interview, facility staff failed to provide proper incontinence care in a manner to prevent potential urinary tract infections for one of one residents reviewed (Resident #2). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as cognitively impaired with a Brief Interview for Mental Status (BIMS) of 0 and had the following diagnoses: Non-traumatic Brain Dysfunction, Unspecified Dementia and Coronary Artery Disease. The MDS identified the resident required extensive staff assist with bed mobility, dressing and personal hygiene and totally dependent on staff for transfers, locomotion on the unit and bathing. The MDS identified the resident as occasionally incontinent of bladder and always incontinent of bowel. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility staff failed to properly maintain a Foley catheter bag off the floor to prevent potential urinary tract infections for one of one residents reviewed with an indwelling catheter (Resident #83). The facility reported a census of 35 residents. Findings Include: 1. Resident #83 did not have a completed Minimum Data Set during the survey. The Electronic Medical Record revealed an admission date of 5/8/23 and had the following diagnoses: spinal stenosis, benign prostatic hyperplasia (BPH) and overflow incontinence. Random observations of the resident revealed the following: a. On 5/15/23 at 10:25 AM, as the resident in a wheelchair in the lobby area near the entrance, the Foley (catheter) bag not properly placed as it touched the carpeted floor. b. [...]

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to answer call lights in a timely manner for two or fourteen residents reviewed. (Residents #4 and #12) The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #4 as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6 out of 15 and had the following diagnoses: COVID-19, Coronary Artery Disease and Chronic Obstructive Pulmonary Disease. The MDS identified the resident required extensive staff assist with most activities of daily living and totally dependent on staff for locomotion on the unit and bathing. Observations of the resident revealed the following on 5/15/23 at the following times: a. At 3:00 PM, the call light to resident's room on, not flashing. [...]