River Valley Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to use a resident-specific pain assessment for one resident (Resident 1) when it inaccurately assessed Resident 1's pain levels. This failure had the potential to cause Resident 1 increased pain due to improperly assessed pain levels and psychosocial harm. During a record review of facility policy titled Pain Assessment and Management dated October 2022, indicated staff were to monitor for the effectiveness of interventions. Policy also indicated cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing or treating pain. Policy further indicated staff were to assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was sanitary and food was stored, prepared, and distributed in accordance with food safety when: 1. The low temp dishwasher sanitizing solution did not meet manufacturer guidelines. 2. Primary handwashing skink for dietary staff was low flow and not warm. 3. Tortillas were not dated once received and were expired. 4. Dirty dishes were found placed under kitchen preparation area. 5. The lid for the dry powder thickener was kept open when not in use. 6. Thickened milk in the fridge was not dated when created. These failures had the potential to result in cross contamination and place residents at risk for developing a foodborne illness.

Inspectors wroteBased on observation, interview, record review, the facility failed to maintain a safe, clean, comfortable and homelike environment when 10 out of 21 resident rooms in the locked unit, and one courtyard in the locked unit had the following: 1. Resident rooms 131, 133, 134, 137, 138, and 140 were observed as undecorated and not personalized to individuals. 2. room [ROOM NUMBER] was found on multiple dates as having a foul, unpleasant urine-like smell. 3. room [ROOM NUMBER] and 141 were observed to have mismatched toilet parts covered in tape, as well as other broken parts. 4. rooms [ROOM NUMBER] were observed to have patchy, or scratched off paint visible to, and near resident beds. 5. Uncovered outlets with patchy paint were found near room [ROOM NUMBER]. 6. The outdoor courtyard for locked unit had uneven pavement, dead plants, no shade, and an unpleasant appearance. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate below 5%, as 10 medication errors were observed out of 28 opportunities. The error rate was calculated by dividing 10 by 28 and multiplying by 100, resulting in an error rate of 35.7%. This failure led to inaccurate dosing and multiple medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store supplies in a medication room. This was evident in one out of two sampled medication storage rooms where unorganized products were found. Additionally, resident care supplies were found under the sink, which further indicated improper storage practices. The facility also failed to properly label resident medications in two out of four sampled medication carts. Disorganized storage of supplies and products in a nursing home can lead to medication errors, delays in treatment, and potential adverse health effects. Failing to properly label resident medications has the potential to put residents at risk for harm from receiving incorrect, expired, and potentially contaminated or ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was in the appropriate form for one of three residents (Resident 7) to meet her dietary needs. This failure had the potential for Resident 7 to aspirate (ingestion of food or fluid into the airway or lungs), choke, and have weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an infection control program was implemented by staff to reduce the spread of infection in the facility when: 1. A COVID outbreak was not reported timely to the Department of Public Health. 2. Certified Nursing Assistant (CNA) F did not perform hand hygiene when doing patient cares. These failures had the potential to result in the development and transmission of infectious diseases to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the communication call light system ( a communication system which relays the call directly to a staff member or to a centralized staff work area) was working for five of seven residents (Residents 21, 55, 69, 81 and 440) sampled for working call lights, when these residents had been given hand bells when their call light cord broke and the Director of Maintenance (DOM) indicated she did not have time to fix their call light cords. This failure had the potential for Resident 21, 55, 69, 81, and 440, to be at risk for accidents and their care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility did not accurately assess Resident 7 when the Minimum Data Set (MDS, a standardized, comprehensive assessment to evaluate resident's health status, functional abilities, and care needs) indicated Resident 7 required partial to moderate assistance with eating; however, the care plan (a document that outlines a resident's specific goals and needs) indicated Resident 7 required extensive assistance with eating. This failure had the potential to not accurately reflect Resident 7's status, which could cause a decline in the resident's status and ability to receive proper nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan for one resident out of three (Resident 238) within 48 hours after admission for respiratory care issues and oxygen needs. This failure had the potential for Resident 238 to not receive effective and person-centered care when no respiratory goals or interventions were included in the baseline care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-center care plan for one of four residents (Resident 26) sampled for care plans, to reflect Resident 26's required need of the assistance of two helpers with Activity of Daily Living (ADL's, which included turning resident in bed, bathing, and changing her brief [incontinent underwear that absorb urine and feces]). This failure had the potential to lead to inaccurate provision of care and adverse health outcomes for Resident 26.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide Resident 7 with extensive assistance while eating her lunch, as deemed necessary by her care plan (a document that outlines a resident's specific goals and needs). This failure had the potential to foster a decrease in the resident's participation in her activities of daily living (ADLs) to maintain good nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an evaluation and documentation, of a red area, was completed for one of two residents (Resident 26) sampled for skin conditions, when Resident 26 was identified to have a red area on her bottom on admission but there was no further documentation about the red area for the next three weeks. This failure had the potential for Resident 26's skin condition to become worse and cause significant pain and negative clinical outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety of one of nine sampled residents (Resident 79) reviewed for accidents and hazards when Resident 79 was found to have nine razors and one pair of tweezers in her room. This failure had the potential for Resident 79 to cause physical and psychosocial harm to herself and to other residents in the secured unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three dietary aides (responsible for dishwashing) was competent on the use of the three-compartment sink (used in food services to properly wash, rinse, and sanitize dishes and utensils) procedure for manual dish washing in the kitchen. This failure placed all residents at risk for cross contamination and acquiring food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Medical Director (MD) supervised the development and implementation of mitigating a scabies outbreak that effected 31 residents. This failure resulted in a six-month scabies outbreak in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI - a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality) when the committee did not develop, implement, and identify performance improvement activities related to a scabies outbreak. Refer to F 880 and F 658. This resulted in 31 residents and all staff, vendors, and visitors being at risk for exposure to scabies.

Inspectors wroteBased on interview and record review the facility failed to ensure the services provided for one of 31 residents (Resident 2) met professional standards of quality during an outbreak of scabies. This resulted in a widespread scabies outbreak over a six-month period and caused pain and suffering for all residents affected by the skin sores.

Inspectors wroteBased on interview and record review the facility failed to identify a scabies (a highly contagious skin infestation caused by human itch mites that causes intense itching of the skin) outbreak, implement appropriate precautions, monitor the effectiveness of the corrective actions and prevent further transmission when: 1. The facility's surveillance system (line listing that tracks infectious outbreaks) was incomplete. 2. Infection control committee did not monitor the scabies outbreak and evaluate the effectiveness of the corrective actions taken. 3. The nursing and housekeeping department did not implement appropriate precautions to prevent spread of scabies outbreak. 4. The staff were not trained in infection prevention and control practices to prevent further spread of scabies outbreak. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety measures were provided to prevent accident hazards for three of five residents sampled for accidents (Resident 1, 4, 8) when the wheels attached to the headboard of the bed were not locked. This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents.

Inspectors wroteBased on interview, and record review, the facility failed to treat one out of three sampled residents (Resident 1) with dignity and respect when direct care staff made Resident 1 wear an incontinent brief and would not take Resident 1 to the bathroom for toileting. This failure had the potential to result in emotional stress, anger, embarrassment, feelings of neglect, and the potential for negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a complete comprehensive care plan was developed for one of two sampled residents (Resident 1) to reflect current individual needs upon admission when: 1-Resident 1 did not have restrictions listed for staff to not use Right arm for blood pressures or any procedures for Resident 1's Right arm due to a previous mastectomy (a surgical operation to remove a breast). 2-Resident 1 did not have weight bearing restrictions listed on the care plan after a Right hip surgery. 3-Resident 1 had no interventions to monitor surgical incision site to right leg with 13 staples every shift for signs and symptoms of infection. This failure resulted in Resident 1's individual care needs to go unrecognized, and the potential for a further decline in Resident 1's physical, mental, and psychological status.

Inspectors wroteBased on interview, and record review, the facility nursing staff failed to get one of two sampled residents (Resident 1) out of bed (OOB) following a hip surgery and per Resident 1's right to get OOB per request for seven consecutive days. This failure had the potential to result in emotional stress, anger, embarrassment, feelings of neglect, and the potential for negative clinical outcomes related to surgical complications of immobility for seven days.

Inspectors wroteBased on interview, and record review, the facility nursing staff failed to complete and accurately document medical records for one of three sampled residents (Resident 1) for activities of daily living (ADLs, basic tasks completed every day that include personal hygiene or grooming, bathing, dressing, toileting, transferring or ambulating, and eating). This failure of incomplete documentation had the potential for resident needs to not be identified or met which could have a negative clinical outcome.

Inspectors wroteBased on interview, and record review, the facility failed to notify the physician of one of three sampled residents (Resident 1) when Resident 1 had a change in condition in a timely manner. This resulted in Resident 1 not receiving timely evaluation and treatment .

Inspectors wroteBased on record review and interview, the facility failed to provide timely and accurate discharge planning for one of three residents (Resident 1) when Resident 1 was not given a 30-day notice of discharge and no physician order was received to initiate discharge planning. This failure resulted in the potential of an unsafe discharge for Resident 1 and caused him anxiety.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure they accurately coded the Minimum Data Set (MDS) for 4 (Residents #49, #81, #59 and #58) of 6 residents reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure they implemented the comprehensive person-centered care plan for 1 (Residents #58) of 23 residents reviewed for comprehensive person-centered care plans. Specifically, the facility failed to implement care plan interventions to prevent Resident #58 from wandering into other resident's rooms.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide medically-related social services by failing to identify the need for a guardian for 1 (Resident #47) of 23 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to have behavior monitoring for the use of an antianxiety medication, document non-pharmacological interventions prior to the use of an antianxiety medication, and have a specific duration for the use of an as-needed (PRN; pro re nata) antianxiety medication for 1 (Resident #27) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have a medication error rate less than 5 percent (%) with a medication error rate of 13.79%. The facility had four medication errors out of 29 opportunities affecting 2 (Resident #10 and Resident #33) of 4 residents reviewed during the medication administration task.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain an infection control program to prevent the transmission/development of infection for 1 (Resident #8) of 7 residents reviewed for infection control. Specifically, the facility failed to ensure that staff implemented enhanced barrier precautions (EBP) for Resident #8.

Inspectors wroteBased on interview, observation, and record review, the facility failed to meet this requirement when a blood draw tourniquet (a device that is used to apply pressure to a limb or extremity in order to stop the flow of blood) remained on a resident (Resident 1 ' s) for an estimated six hours unnoticed and unattended to. This resulted in Resident 1 ' s hand being swollen and red, and had the potential for serious injury. Findings A review of Resident 1's clinical record, indicated Resident 1 was admitted to the facility with diagnoses including dementia (memory and mental function loss), diabetes, communication deficits (inability to speak), and muscle weakness. On 3/27/24 at 1:45 PM, Resident 1 was observed to have a phlebotomy (blood draw) tourniquet around his wrist, tied tightly in a slip knot. The tourniquet was observed to be pressing deeply into Resident 1 ' s skin; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician in a timely manner for one of three sampled residents (Resident 1) when Resident 1's urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine) results were not obtained as ordered by the physician on 11/9/2023. The facility notified the physician that the above order was not completed on 11/17/23, seven days later. The facility failed to notify the physician in a timely manner when the second UA was sent on 11/17/2023 and the Urine Culture (a lab test to check for bacteria or other germs in a urine sample) was received on 11/19/2023. The physician was notified on 11/22/2023, three days later. These failures prevented Resident 1's attending physician from having the necessary information to determine the need to alter Resident 1's treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's plan of care for one of three sampled residents (Resident 1), when Resident 1 had a new physician's order for wound care treatment that was not entered to Resident 1's treatment administration record (TAR). This resulted in Resident 1 not receiving treatments as ordered by the physician and had the potential to negatively affect Resident 1's physical wellbeing.

Inspectors wroteBased on interview, record review and observation, this regulation was not met when two of seven sampled residents (Residents 2 and 3) received wilted, discolored salad. This resulted in the salad appearing unapalatable to both residents and did not meet the facility's policy for food storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status when staff did not identify insidious weight loss (gradual, unintended, progressive weight loss over time), implement or modify a plan of care that was individualized and consistent with the resident's needs or preferences for one of four sampled residents. (Resident 19) These failures resulted in severe weight loss and put Resident 19 at risk for further health decline.

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary environment in the kitchen when: 1. There were boxes of food in the walk-in refrigerator and freezer that were not stored off the floor. 2. There was an opened box of kernel corn in the freezer. 3. There was stored food items that were undated. This failure had the potential for cross-contamination of bacteria or other microorganisms (very small organisms undetected by the eyes) to be unintentionally transferred to other surfaces and the food with a harmful effect causing food-borne illnesses for 88 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient and competent nursing staff to implement the plan of care for three of 46 sampled residents (Residents 19, 78 and 86), and five out of six confidential resident interviews when: 1. Resident 78 rolled out of bed while not having enough assistance during bed mobility (repositioning). This failed practice resulted in hospitalization for treatment of a fractured right femur. 2. Resident 19 did not have enough mealtime assistance and meal intake documentation was not accurate. This resulted in severe unplanned weight loss. 3. Resident 86 waited an extended period of time for her call light to be answered, resulting in her sitting in wet briefs for three and a half hours and embarrassment. 4. Confidential interviews indicated slow call light response. [...]

Inspectors wroteFindings: A review of facility policy titled, Antipsychotic Medication Use, revised April 2007, indicated diagnoses alone do not warrant the use of an antipsychotic unless the following criteria are met: the behavioral symptoms present a danger to the resident or others which may include inconsolable or persistent distress for example continuous screaming and one or both of the following, symptoms are identified as being to mania or psychosis or behavioral interventions have been attempted and included in the plan of care. Based on assessing the resident's symptoms and overall situation the physician will determine whether to continue, adjust or stop existing antipyschotic medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store wasted medications in a secure container when discarded medications in Medication room [ROOM NUMBER] were not securely stored or destroyed. This failure resulted in unsecured medication waste being accessible to licensed nursing staff.

Inspectors wroteBased on observation, staff interviews and review of facility documents, the facility failed to provide food and drinks at a palatable temperature for four residents in a confidential interview and four sampled residents (Resident 48, 76, 83 and 295). These failures have the potential to lead to residents experiencing decreased pleasure and lead to negative clinical outcomes and further compromising the nutritional and medical status of residents.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and implement plans of action to correct deficiencies for: 1. Resident 19's severe unplanned weight loss. These failures resulted in severe weight loss for Resident 19 at put her at risk for further health decline. Refer to F692. 2. Dietary services did not meet the nutritional needs of the residents. These dietary service failures put all residents for nutritional deficits that could contribute to possible unplanned with loss and health decline. Refer to F803, F804, F806, and F908.

Inspectors wroteBased on observation, interview and record reiew, the facility failed to provide toileting care and proper storage of soiled clothing for 1 of 3 residents (Resident 86) when Resident 86 was left to wait in her soiled briefs for four hours and her soiled pajama pants were found in the resident's closet on top of her clean clothes. This failure resulted in Resdient 86 experiencing avoidable incontinence (loss of bladder control), and feeling wet and embarassed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and clean environment when: 1. Damaged ceiling tiles were observed in the laundry area and facility hallway. 2. Accumulated dust and lint was observed on the flat surfaces of the washers in the laundry area. These failures had the potential to compromise fire safety, allowing flames to penetrate through holes in the ceiling tiles in the event of a fire, and microorganisms to grow in the accumulated dust and lint.

Inspectors wroteBased on observation and interview, the facility failed to report an injury of unknown origin for one of six residents (Resident 68) when she had a hematoma (clotted blood that forms from an injury) to her left temple and an abrasion (scrape) to her left middle finger that required evaluation at the hospital. This had the potential for delaying investigations into injuries of unknown origin by facility and required reporting agencies to be able to rule out abuse.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure one of 88 sampled residents (Resident 83) received treatment and care related to physical, occupational, and behavioral restorative therapies and not honor resident choices. This failures had the potential to result in Resident 83 not receiving individualized care needed to maintain his highest level of well-being. Findings; Resident 83's record was reviewed. Resident 83 was re-admitted to the facility on [DATE], with a diagnosis that included, Dysphagia (difficulty swallowing), neck fracture, and anxiety. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 11/19/21, indicated that Resident 83 was cognitively (ability to think and reason). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate assistance to prevent avoidable accidents for one of 46 sampled residents (Resident 78), when Resident 78 rolled off her bed while being assisted by staff with bed mobility (moving from a lying position, turning from side to side, or positioning the resident while in bed). This failure resulted in Resident 78 sustaining a right femur (upper bone of the leg) fracture, and placed Resident 78 and other residents in the facility at risk of harm from potential injury, when being assisted with bed mobility without sufficient staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered laboratory (lab) blood tests were implemented for one of five residents (Resident 18). This failure had the potential for Resident 18 to not receive timely treatment and/or adjustment to the medication which may cause an adverse side effect.

Inspectors wroteBased on observation, staff interviews and review of facility documents, the facility failed to ensure the menu was followed on 12/1/21 when greater than 5 residents on puree and mechanical soft diets received incorrect portion sizes for the small, regular, and large portion diets. These failures have the potential for residents to receive the wrong caloric intake when not following the menu, which could result in over nutrition or undernutrition, can result in the substitutes not being equal of nutritive value which may result in a significant weight loss and further compromising the nutritional and medical status of residents.

Inspectors wroteBased on observation, staff interviews and review of facility documents, the facility failed to ensure the menu was followed on 12/1/21 when: 1) One sampled resident (Resident 1) was not offered a protein-based substitute of similar nutritive value for eggs. 2) One sampled resident (Resident 76) was not able to receive coffee with her morning meal when repeatedly requested. 3) One sampled resident (Resident 295) was not able to receive coffee with her noon meal when repeatable requested. Failure to provide food in accordance with resident preferences may result in decreased meal satisfaction, substitutes not being equal of nutritive value, over all caloric intake, and may result in a significant weight loss and further compromising the nutritional and medical status of residents.

Inspectors wroteBased on observation, interview and record review the facility failed to replace a contaminated oxygen mask (mask worn over the mouth and nose) for one two sampled residents when Resident 46's oxygen mask and tubing was found on the floor. This failure placed Resident 46 at risk for infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure the plate warmer was in full operational capacity. This failure resulted in three sampled residents (Resident 48,76, and 83) and four residents in a confidential interview with the potential for all 84 of the facility's residents to get served cold food at a unpalatable temperature, leading to residents experiencing decreased pleasure and further compromising the nutritional and medical status of residents.