Souris Valley Care Center

Inspectors wroteBased on record review, review of the facility reported incident (FRI), review of facility policy, and resident and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 supplemental resident (Resident #27) who displayed physical behaviors towards another resident. Failure to protect Resident #31 from physical abuse may have resulted in pain or injury and placed all residents at risk for physical harm, pain, mental anguish, and emotional distress. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.

Inspectors wroteBased on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and resident and staff interviews, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (Residents #3, #24, and #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interviews, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 12 sampled residents (Resident #2 and #34). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure adequate monitoring for 2 of 5 residents (Resident #2 and #32) reviewed for psychotropic medications. Failure to complete a baseline assessment before starting an antipsychotic and periodically while on the medication may result in undetected side effects and adverse consequences related to the antipsychotic medication.

Inspectors wroteBased on record review, review of facility policy, review of professional standards, and staff interview, the facility failed to ensure residents remained free of significant medication errors for 1 of 1 sampled resident (Resident #32) with a significant medication error. Failure to administer medication and monitor lab results according to physician's orders may inhibit the effectiveness of the medications and cause subtherapeutic levels.

Inspectors wroteBased on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remain free from abuse for 1 of 5 sampled residents (Resident #2) who was subjected to physical abuse by another resident. Failure to ensure the facility had processes in place to meet the needs of residents resulted in a bruise to Resident #2's face and placed all residents at risk for physical harm, pain, mental anguish, and emotional distress.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician for 1 of 1 sampled resident (Resident #3) reviewed for falls. Failure to notify the resident's physician of changes in condition promptly may prevent the physician from altering treatment/care.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 1 of 9 sampled residents (Resident #2). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of facility policy, review of the facility reported incident (FRI) and investigation, and staff interviews, the staff failed to provide appropriate supervision and use of assistive devices for 2 of 2 sampled residents (Resident #1 and #2) who required staff assistance while bathing. Failure to utilize the bath chair safety strap during bathing resulted in a fall with a fracture for Resident #1 and placed all residents at risk of accidents, falls, and/or injuries. During the on-site FRI investigation, the survey team determined noncompliance with regulatory requirements existed on 11/11/25 when facility staff failed to utilize the bath chair safety strap resulting in a fall/fracture.*On 11/18/25 at 2:03 p.m. the survey team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 11/11/25. [...]

Inspectors wroteBased on information received from the facility reported incident (FRI), record review, and staff interviews, the facility failed to thoroughly investigate and document an alleged violation of neglect for 1 of 1 sampled resident (Resident #1) who fell from a bath chair. Failure to thoroughly investigate an incident of potential neglect may result in future neglect and or harm to other residents.

Inspectors wroteBased on record review, review of facility policy, review of the facility reported incident (FRI) and investigation, and staff interviews, the staff failed to provide treatment and care in accordance with professional standards of practice to maintain residents' highest level of functioning for 1 of 1 sampled resident (Resident #1) who experienced a fall from the bath chair. Failure to ensure a licensed nurse performed a full-body assessment after a fall may have resulted in further injury and/or pain to the resident.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #18) with Multi-Resistant Staph Aureus (MRSA) (a type of contagious infection resistant to antibiotics) in a wound. Failure to follow infection control practices related to location of a dressing change and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. During the on-site recertification survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/21/25 at 3:55 p.m. The IJ was identified when a staff nurse performed a dressing change in the medication room and failed to wear Personal Protective Equipment (PPE) (a gown). This finding placed all residents, staff, and visitors at risk for infection and/or spread of infection. [...]

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 4 of 13 sampled residents (Residents #3, #13, #28, and #189). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, review of the facility reported incident (FRI), review of the facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and proper use of assistive devices to prevent accidents for 1 of 2 sampled residents (Resident #13) and 4 supplemental residents (Residents #7, #12, #23, and #30) observed during full body mechanical lift (Hoyer) transfers. Failure to ensure staff use a mechanical lift properly placed residents at risk of serious injury from falls.

Inspectors wroteBased on observation, record review, review of facility policy and resident and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected resident's dignity and individuality for 1 of 9 sampled residents (Resident #7) who voiced concerns regarding sleep and toileting cares. Failure to honor Resident #7's choice for napping, bedtime, and toileting does not enhance the resident's quality of life and may result in decreased self-esteem, quality of life, and increased pain.

Inspectors wroteBased on record review, review of the facility reported incident investigation, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 closed record (Resident #1) receiving insulin. Failure to administer insulin according to a physician's order may have contributed to Resident #1's hospitalization. This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 5 sampled residents (Resident #35) who required staff assistance and a gait belt with transfers. Failure to provide adequate assistance and/or use the assistive devices appropriately during transfers placed the residents at risk for accidents, falls, and/or injuries. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/16/24 at 5:15 p.m. The IJ resulted from staff failure to provide sufficient supervision and use the assistive device (gait belt) in a manner to avoid a fall and/or potential injury. * 04/16/24 at 5:29 p.m., The survey team contacted the State Survey Agency (SSA) to report the findings and discuss potential immediate jeopardy (IJ). [...]

Inspectors wroteBased on record review, policy review, and resident and staff interviews, the facility failed to provide care and services to control pain for 1 of 1 sampled resident (Resident #31) reviewed for pain management. Failure to administer as needed (prn) pain medications and inform the physician of increased use of prn pain medication resulted in Resident #31 experiencing anxiety and mental anguish and may have contributed to the resident experiencing increased and/or unresolved pain.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 14 sampled residents (Resident #20, #29 and #35) and one supplemental resident (Resident #44). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Failure to code discharge status may affect appropriate discharge planning and follow-up if needed.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the resident's current status for 5 of 14 sampled residents (Resident #17, #27, #29, #35, and #41). Failure to revise the care plan limited the staff's ability to communicate care needs and ensure continuity of care for each resident.

Inspectors wroteBased on observations, record review, facility policy, and staff interview, the facility failed to promote care in a manner that maintained or enhanced residents' dignity for 1 of 14 sampled residents (Resident #14) and 1 supplemental resident (Resident #6) who required assistance with dressing. Failure to ensure the residents wore clean clothing and were fully dressed the resident following cares does not promote mental well-being or dignity.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 4 sampled residents (Resident #17) with weight loss. Failure to notify the physician of these changes may have prevented the physician from altering the treatment/care provided to the resident.

Inspectors wroteBased on observation, record review, review of manufacturer's instructions for use, and staff interview the facility failed to ensure staff followed standards of practice for 1 of 1 resident (Resident #29) observed during administration of intermediate acting insulin. Failure to administer intermediate-acting insulin within fifteen minutes of a meal may result in a hypoglycemic (low blood sugar) reaction.

Inspectors wroteBased on observation, record review, staff interview, and review of facility policy, the facility failed to ensure staff provided care and services for 1 of 1 sampled resident (Resident #27) with orders for a CAM Boot (Controlled Ankle Motion boot - an orthopedic device prescribed for the treatment and stabilization of severe sprains, fractures, tendon, or ligament tears in the ankle of foot). Failure to document application and removal of an orthopedic device, and to follow physician's orders for elevating legs/heels, may result in pain and/or worsening of resident's condition.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status or 1 of 4 sampled residents (Resident #35) with weight loss. Failure to reassess/monitor weight variances may delay needed treatment for weight loss and alter the resident's ability to maintain sufficient nutritional status.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/25/23 Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled resident (Resident #24) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident at risk of receiving unnecessary medications and experiencing adverse drug effects.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 6 sampled residents (Resident#17, #35 and #195) observed with enhanced barrier precautions (EBP). Failure to practice infection control standards related to linen handling, hand hygiene, and glove use, and ensure staff use the proper personal protective equipment (PPE) has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to assess each resident's pneumococcal status and provide education to residents and/or their legal representatives regarding the benefits and potential side effects of receiving the vaccination for 1 of 5 sampled residents (Resident #17) reviewed for immunization status. Failure to offer pneumococcal vaccine to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contract pneumonia and spread the infection to other residents, visitors, and staff.