Valley Nursing and Rehabilitation Center

Inspectors wroteBased on record review, staff, family, police department and Medical Director interviews, the facility failed to protect a resident's right to be free from physical abuse when Resident #1 became combative during incontinence care and Nurse Aide (NA) #1 forcibly continued to provide care and grabbed [the resident] by the lower thigh and back and then gave him a hard push in an attempt to finish care. This resulted in the resident suffering a broken femur (thighbone) in the resident requiring traction (the application of a slow, steady pulling force to a part of the body) and 200 micrograms (mcg) of Fentanyl (an opioid medication given for pain) while in transit to the emergency room. The resident was administered Dilaudid (another opioid medication) while in the emergency room for pain, and required surgical intervention. [...]

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to follow professional standards of practice for the safe administration of medications for 1 of 1 resident reviewed for self-administration of medications (Resident #65). Resident #65, who had been assessed as unable to self-administer medications, had medications left at his bedside without nursing supervision.

Inspectors wroteBased on observations, record reviews, and staff and Nurse Practitioner interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.69% for 1 of 4 residents observed during the medication administration (Resident #6).

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to secure controlled substance medications under a double lock in 1 of 3 medication rooms reviewed for medication storage (Main medication room).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when the Wound Nurse did not doff (remove) her gloves, perform hand hygiene and don (put on) clean gloves before moving to a second wound on Resident #10. The deficient practice occurred for 1 of 4 staff members observed for infection control practices (Wound Nurse).

Inspectors wroteBased on record review, and staff and resident representative interviews, the facility failed to complete a comprehensive discharge summary that included the name of the home health company and their contact information and failed to ensure education regarding catheter care was provided to the Resident Representative prior to discharge for 1 of 3 residents reviewed for discharge (Resident #1).

Inspectors wroteBased on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews the facility failed to notify the Medical Director of Resident #1's documented allergy to aspirin with a history of a gastrointestinal bleed, recent fall with fracture, and new immobility for further orders regarding anticoagulation. Resident #1's family had expressed concerns to the Director of Nursing (DON) on 12/11/2024 regarding Resident #1 not receiving an anticoagulant after falling at home and sustaining multiple fractures of her pelvis and lumbar spine. Resident #1 had a documented allergy to aspirin and the NP instructed the Assistant Director of Nursing (ADON) to reach out to the MD for further direction. [...]

Inspectors wroteBased on record review, and staff, Resident, Responsible Party (RP), Nurse Practitioner, and Medical Director interviews, the facility failed to protect a resident's right to be free from neglect when they failed to notify the Medical Director that Resident #1 had a documented allergy to aspirin with a history of gastrointestinal bleed, recent fall with fracture, and new immobility on 12/11/24 when Resident #1's family expressed concerns to the Director of Nursing (DON) that Resident #1 was not receiving anticoagulant. The Nurse Practitioner instructed the Assistant Director of Nursing to reach out the Medical Director for guidance an anticoagulation and failed to communicate or collaborate with the Medical Director herself. [...]

Inspectors wroteBased on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to seek emergent medical attention when Resident #1 who had a recent history of spine and pelvic fractures and anticoagulation therapy prior to admission, experienced increased leg swelling, pain and an ordered venous doppler study (a non-invasive diagnostic procedure that uses sound waves to examine the circulation in the body's veins and arteries) could not be scheduled for at least three days after it was ordered. On 12/27/2024, Resident #1 was noted to have increased edema (swelling), a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot), and pain to her left lower extremity. [...]

Inspectors wroteBased on record review, and staff, Resident, Resident Responsible Party (RP), Nurse Practitioner, and Medical Director interview the facility Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director after Resident #1's RP voiced concerns on 12/11/2024 that Resident #1 was not receiving an anticoagulant (blood thinning medication, used to prevent blood clots) after having a fall at home and sustaining multiple fractures of the pelvis and lumbar (lower back) spine, and was not as mobile as she had been prior to admission to the facility. The Assistant Director of Nursing (ADON) contacted the NP on 12/11/2024 at which time the NP ordered aspirin which was later discontinued due to a listed allergy due to a history of gastrointestinal bleeding. [...]

Inspectors wroteBased on record review, Nurse Practitioner (NP), Resident, Resident Responsible Party (RP), and staff interviews, the facility failed to manage a resident's pain (Resident #1) when she experienced increased pain combined with swelling and redness on 12/18/2024 in her left lower extremity. Resident #1 reported she had experienced pain to her left leg on 12/18/2024 and it got worse until she called her family and requested to go the hospital on [DATE]. Resident #1's RP called the facility on 12/28/2024 and requested that Resident #1 be sent to the hospital due to increased pain and swelling in her left leg. Emergency Medical Services (EMS) were called to the facility and noted Resident #1 to have an elevated blood pressure of 182/74 (normal is 120/80) and pain of 8 out of 10 on a numerical pain scale (indicative of severe pain). [...]

Inspectors wroteBased on record review, and staff interviews, the facility failed to report an allegation of neglect to the state survey agency for 1 of 3 residents reviewed for neglect (Resident #1).

Inspectors wroteBased on record review, observation, crash cart checklist, and staff, Respiratory Therapist, and Medical Director (MD) interviews the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) when Resident #103, who was a full code had agonal breathing (a state of breathing of gasping for air due to the brain receiving insufficient oxygen) and went pulseless, failed to immediately utilize the overhead paging system to call staff to Resident #103's room (code blue), and failed to immediately active Emergency Medical [NAME] (EMS). Once the Respiratory Therapy recognized the need for CPR, they failed to implement the use of the Automated External Defibrillator (AED), failed to have available or use an oral airway, and the regulator on the emergency oxygen tank on the crash cart only went to 10 liters. [...]

Inspectors wroteBased on observations, record review, and resident, staff, Nurse Practitioner (NP), Medical Director (MD), and Pharmacist interviews the facility failed to assess a resident and initiate the sepsis protocol when Resident #96, who was continuously ventilator dependent, was found by Nurse #1 between 8:00 and 9:00 pm on 9/16/2024 to have a fever of 100.4 degrees Fahrenheit (F) (normal is 98.6 degrees), a heart rate of 116 beats per minute (normal is 60-100 beats per minute), and a respiratory rate of 24 breaths per minute (normal is 12-20 breaths per minute). [...]

Inspectors wroteBased on observation, record review and staff interviews the facility failed to ensure that a nurse was competent in responding to medical emergencies and activating emergency procedures with emergency medical services (EMS). Resident #103 was a Full Code and experienced sudden cardiac arrest on [DATE]. Nurse #3 was unable to locate the crash cart, the automated external defibrillator and did not immediately call 911. Resident #103 was pronounced deceased by EMS on [DATE] at 7:50 pm. The deficient practice was identified for 1 of 5 nurses (Nurse #3) reviewed for competency and had the high likelihood for causing serious harm to other residents. Immediate jeopardy began on [DATE] when Nurse #3 did not demonstrate competency in responding to a medical emergency. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. [...]

Inspectors wroteBased on record reviews and staff interviews the facility failed to follow their Abuse, Neglect, and Exploitation policy by failing to screen a new employee and initiate protective measures to safeguard residents from potential abuse and neglect when they hired Dietary Aide (DA) #1 with one pending allegation of Abuse of a Resident on the North Carolina Nurse Aide Registry for 1 of 5 employees reviewed for screening of employees (DA#1). The facility also failed to implement their abuse policy and procedures in the areas of reporting by not submitting an initial allegation report to the Division of Health Service Regulation (DHSR) within 2 hours of the facility being made aware of an allegation of abuse (Resident #81) and not notifying local law enforcement of an allegation of neglect (Resident #225) for 2 of 3 sampled residents reviewed for abuse.

Inspectors wroteBased on observations, record reviews, and resident and staff interviews, the facility failed to keep an accurate account of controlled substances (Resident #90 and Resident #110), failed to remove discontinued controlled substances from the medication cart (Resident #90), and administered medications to Resident #113 from a bottle that was labeled for another person. This affected 3 of 3 residents reviewed for pharmacy services.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to: 1) dispose of loose and unidentified tablets of various shapes and sizes from medication cart (300 Hall Bottom), 2) discard expired medications from medication cart (600 Hall), 3) store medications in accordance with the manufacturer's storage instructions (300 Hall Bottom and 100 Hall), and 4) properly store and date a open vial of Tuberculin Purified Protein Derivative (PPD) (600 hall) for 3 of 8 medication carts reviewed for medication storage.

Inspectors wroteBased on record review, staff interviews, the facility failed to ensure a staff member had no pending or substantiated allegations of Resident Abuse or Neglect on the North Carolina Nurse Aide Registry for 1 of 5 employees (Dietary Aide #1) reviewed for resident abuse.

Inspectors wroteBased on record review and staff, family member, and regional ombudsman interviews, the facility failed to notify the Regional Ombudsman of a facility initiated discharge for 1 of 4 residents reviewed for dischage (Resident #308).

Inspectors wroteBased on record review and staff interviews the facility failed to develop a baseline care plan that addressed a resident's wound or indwelling catheter for 1 of 5 residents reviewed for pressure ulcers (Resident #58).

Inspectors wroteBased on record review, staff, and Wound Provider interviews the facility failed to provide a physician ordered treatment to an arterial ulcer (an ulcer due to inadequate blood supply) over a weekend for 1 of 5 residents (Resident #49) reviewed with wounds. In addtion, a nurse did remain at the bedside to confirm a resident had taken his medications for 1 of 1 resident assessed as unable to self administer medications (Resident #44).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a comprehensive discharge summary that included a recapitulation of stay for 1 of 3 residents reviewed for discharge (Resident #306).

Inspectors wroteBased on observation, record review, and staff and Wound Provider interviews, the facility failed to provide a physician ordered treatment to a pressure ulcer over a weekend for 1 of 5 residents reviewed for pressure ulcers (Resident #76).

Inspectors wroteBased on observations, record review, and staff and Nurse Practitioner interviews, the facility failed to supervise a cognitively impaired resident who exited the facility through a sliding window in his room which resulted in a skin abrasion on the resident's knee for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #308).

Inspectors wroteBased on observations, record review, Registered Dietitian and staff interviews, the facility failed to administer a high protein, fiber fortified nutritional supplement per the physician's order for 1 of 3 residents reviewed for tube feeding (Resident #94).

Inspectors wroteBased on observations, record reviews and interviews the facility failed to don Personal Protective Equipment (PPE) before entering a resident's room and failed to doff PPE after exiting a resident's room under transmission-based precautions for COVID-19. The facility also failed to utilize hand hygiene after removing gloves during a wound dressing change for 2 of 3 residents reviewed for infection control (Resident #46 and Resident #76).

Inspectors wroteBased on record review, observations, and interviews with the Medical Director, Registered Dietitian, and staff the facility failed to ensure the volume rate settings on the feeding pumps were correct to administer water flushes as ordered by the physician for 2 of 3 residents reviewed for the care of a feeding tube (Resident #1 and Resident #2).