Surprise Valley Community Hospital D/P SNF

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a care policy for residents that required end of life care. This had the potential for residents not to receive compassionate, dignified, and personalized care during their final days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report to the California Department of Public Health (CDPH), a physical abuse allegation immediately or within two (2) hours for one of three sampled residents (Resident 1), when Resident 1 made an allegation that she was treated rough during a shower and this was not reported to the facility's Abuse Coordinator or to CDHP in accordance with the facility's Abuse Policy. This failure had the potential of creating an environment where abuse allegations are not timely reported to the appropriate agencies, and result in all residents being at risk of physical and emotional abuse without appropriate investigations, leading to an unsafe environment for residents and no consequences for an actual abuser. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food was stored, prepared and served under sanitary conditions when: 1. Stainless-steel prep area was unsanitary 2. Large mixer was difficult to sanitize 3. Walk-in freezer had ice build-up 4. Coffee station was uncleanable 5. Kitchenware had burnt-on food 6. Painted center island were difficult to sanitize 7. Painted wood cabinets were difficult to sanitize 8. Ceiling above the stove was damaged 9. Area above laminate splash guard was difficult to sanitize 10. Kitchen and dishwashing room walls were dirty 11. Dry storage entryway was uncleanable 12. Dry storage shelving was uncleanable 13. Dry storage area ceiling was damaged 14. Divider wall had broken tile 15. Stainless-steel storage table was uncleanable 16. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the care plan was developed and revised to reflect the current status of the resident for three of four sampled residents (Residents 51, 57 and 157) when: 1. Resident 51's care plan was not revised to include a rash. 2. Resident 57's care plan was not revised to include skin breakdown. 3. Resident 157's care plan was not revised to include comfort care. These failures had the potential to result in the residents' needs not being identified, and resident's feeling depressed with poor self-esteem, and had the potential for the residents to acquire new pressure ulcers and/or worsen current pressure ulcers, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS). The failure to submit the required data, staffing hours and census information, can prevent determining whether or not an adequate level of staff is working at a given time, leading to inadequate care of residents and adverse clinical outcomes.

Inspectors wroteBased on interview and record review, this regulation was not met when the facility failed to have a program in place to prevent an outbreak by testing their water for legionella bacteria, (Legionaire's Disease, a potentially fatal lung infection). This had the potential for residents, staff and visitors to become infected with legionella bacteria and cause illness and possibly death.

Inspectors wroteBased on interview and record review, the facility failed to follow policy requirements of the facility policy titled, Weight Assessment & Interventions for one of twelve residents sampled by not reweighing Resident 13 (R13) when weight loss was discovered. The failure to follow the policy requirement affected one resident creating the potential for additional unaddressed weight loss and a detrimental clinical outcome for residents.

Inspectors wroteBased on interview, observation and record review, the facility failed to meet this requirement when a medication for one (Resident 10) of nine sampled residents did not match Resident 10's current physician order, and did not meet professional pharmacy standards of practice for drug labeling. This resulted in the potential for overdosing medication and harm to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the willful neglect of one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 intentionally neglected to check Resident 1's blood sugars and administer insulin (a medication to lower blood sugar) as ordered by the physician, then LVN 1 falsified Resident 1's medication record by recording blood sugar results that she never obtained and insulin coverage that she never provided, nine times between November and December, 2023. This failure resulted in abnormal blood sugar levels requiring additional insulin to stabilize Resident 1's blood sugars and had the potential to have serious negative outcomes to Resident 1's health, by not monitoring and controlling his blood sugars with insulin.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse when Certified Nursing Assistant (CNA) 1 slapped Resident 1 in the face. This resulted in anger, frustration and emotional distress for Resident 1 and had the potential for all residents under the care of CNA 1 to be subjected to mistreatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 11 of 16 sampled residents (Residents 3, 4, 5, 7, 12, 11, 12, 14, 16, 21, and 22) had interdisciplinary (interventions from all departments) and comprehensive person-centered care plans that addressed their preferences (choices), goals (measurable expected outcomes) and interventions (care and services necessary to achieve those goals) when; 1. [...]

Inspectors wrote8. On 5/4/22 at 12:22pm, an interview and a concurrent review of Resident 4's MRRs was conducted with Medical Records staff (MR) B. MR B described that the facility's process for managing the Consultant Pharmacist's (Pharm) D's monthly MRRs was that Pharm D emailed the reviews to the MR Director (MRD). The MRD then brought them to the weekly clinical IDT meeting for the physicians to review and address. MR B stated, the DON is not involved in this process. MR B stated the MR department will give the nurses any MRRs that have order changes and then the MR department scans the completed MRRs into the residents' records. Resident 4 was admitted on [DATE] with diagnoses that included, major depressive disorder (severe depression) and emotional lability (uncontrollable laughing, crying or irritability). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 15 of 16 sampled residents (Residents 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, 16, 17, 18, 21, and 22) who received psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior), received the necessary monitoring of labs (tests used to evaluate the level of medications in the body), adverse side effects, target behaviors to assess effectiveness, gradual dose reductions (GDR); [...]

Inspectors wroteBased on interview, record and policy review, the facility failed to provide a safe, sanitary, and comfortable environment when they failed to ensure that there was a dedicated facility-wide Infection Control Program (ICP) that prevented, identified, reported, investigated and controlled infections based on national standards; (Centers for Disease Control (CDC), Society for Healthcare Epidemiology of America ([NAME]), McGeer's Criteria and National Healthcare Safety Network (NHSN) are examples of nationally accepted standards), and failed to review their ICP policies annually. This had the potential not to control infectious and communicable diseases before they spread to residents, staff, and visitors.

Inspectors wroteBased on interview, record, and policy review, the facility failed to ensure that 20 of 20 residents (Residents 1, 3, 4, 5, 7, 8, 9, 10, 14, 16, 17, 18, 21, 22, 23, 24, 25, 26, 27, and 28) who were over the age of 65, were educated, offered and/or received the pneumococcal (a serious pneumonia in the lungs caused by streptococcal bacteria) vaccine according to the facility's policy. This widespread failure represented a systemic failure which resulted in substandard quality of care for the facility residents and had the potential for vulnerable residents to be unprotected from pneumococcal pneumonia which could result in increased risk for contracting pneumonia with its associated complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 6 of 15 sampled residents (Residents 4, 7, 11, 12, 16, and 22) were provided with sufficient information, in advance, by their physicians which informed them of the risks, benefits, options and alternatives to treating their behaviors with psychotherapeutic drugs (drugs that affect mood, behavior, thoughts, and perception). The facility used a Psychotropic Medication Informed Consent (ICO) which contained all of the necessary information about the psychotherapeutic medication's reason for use, risks, benefits, adverse side effects, and non-pharmacological (non-medicine) interventions that had been tried unsuccessfully prior to offering medication. [...]

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure that they thoroughly assessed the needs of their resident population as a foundation to ensure that they had the necessary resources to provide quality care to their residents, when they had not conducted a facility-wide risk assessment. This failure contributed to substandard quality of care findings, an extended survey, unnecessary use of psychotropic drugs (drugs that alter mood and behavior), implementation of standardized immunization practices, competent nurses and the unrealized resident care areas that needed improvement.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement a plan of action to correct deficiencies related to unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) and infection control (Refer to F 756, 758, 880, 881, and 883). As a result, widespread deficiencies were present regarding unnecessary psychotropic medications and infection control that had the potential to harm all residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility did not have the required membership at its Quality Assessment and Assurance (QAA) meetings when the Medical Director did not attend any of the meetings, and the Administrator (Admin B) and the Director of Nurses (DON) missed one quarter of the meetings. This had the potential for unidentified resident care issues to occur, as well as a lack of medical oversight, which could lead to negative clinical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to establish an antibiotic stewardship program that followed nationally recognized standards and included antibiotic use protocols and a system to monitor antibiotic use for two of three sampled residents reviewed for antibiotic use (Residents 10 and 14). These residents were prescribed antibiotics for a urinary tract infection (UTI) without signs or symptoms of infection or a physician's note indicating the need for antibiotics in the absence of symptoms. This resulted or had the potential to result in Residents 10 and 14 receiving antibiotics which were unnecessary with a potential for adverse side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of two sampled residents (Resident 7) was evaluated and informed of the risks and benefits prior to implementing a bed alarm restraint (an alarm that sounds when a resident changes position in bed). This had the potential to frighten Resident 7 when she moved in bed and result in discomfort and pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nursing staff received ongoing training and evaluations of their skills to ensure that vulnerable residents with behavioral health problems were receiving appropriate care for both pharmacological (medication) and non-pharmacological (no medication) interventions, when 15 of 16 sampled residents were found to have received unnecessary psychotropic drugs (drugs that alter mood and behavior). Refer to F758 This resulted in the widespread use of unnecessary psychotropic drugs, substandard quality of care and had the potential to prevent residents from attaining or maintaining their highest practicable level of psychosocial and emotional well-being.