Valley Senior Living on Columbia

Inspectors wroteBased on -review of a facility reported incident (FRI), record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced unwanted sexual contact from another resident (Resident #1). Failure to protect residents from sexual abuse places all residents at risk for psychosocial harm and mental and emotional distress.

Inspectors wroteBased on record review, review of the facility reported incident (FRI) investigation, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #150) who fell during a staff assisted transfer. Failure to utilize the gait belt resulted in Resident #150's fall/fracture and placed all residents transferred with a gait belt at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.

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 1 of 35 sampled residents (Resident #36). 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.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 12 sampled residents (Resident #30, #153, and #275) observed during cares/wound care. Failure to practice infection control standards related to enhanced barrier precautions (EBP), perineal care, catheter cares, dressing changes, and hand hygiene, has the potential to spread infection throughout the facility.

Inspectors wrote2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision necessary to prevent accidents for 1 of 1 sampled resident (Resident #165) who required one to one supervision with meals. Failure to stay with the resident while eating as care planned places the resident at risk for choking.

Inspectors wroteBased on observation, record review, review of the facility policy, and staff interview, the facility failed to develop a comprehensive care plan for 2 of 5 sampled residents on oxygen (Resident #32 and #47). Failure to develop a comprehensive care plan limited staffs' ability to communicate needs and ensure the continuity of care.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to provide care and services to prevent the development of pressure ulcers for 1 of 8 sampled residents (Resident #165) with prevalon boots (used for pressure relief) as ordered by the provider. Failure to apply the pressure relief boots as ordered may result in the development/worsening of pressure ulcers.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide appropriate toileting for 1 of 29 sampled residents (Resident #98) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents' records contained the hospice election form for 1 of 5 sampled residents (Resident #79) receiving hospice services. Failure to obtain this document limits staff's ability to ensure coordination of care between the facility and the hospice.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for (2 of 21) sampled residents (Resident #49, and #154) and one supplemental resident (Resident #56) observed during personal cares. Failure to follow infection control standards related to hand hygiene and emptying of a urinary bag has the potential to spread infection throughout the facility and could transmit those infections to residents, staff, and visitors. Findings Include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 05/15/24. This policy, revised in May 2023, stated, . all personnel shall follow the handwashing/hand hygiene procedures . 2. Before and after direct contact with residents. Review of the facility skills validation titled Emptying Urinary Drainage Bag occurred in 05/15/24. [...]

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to follow a physician's order for removal of a foley catheter for 1 of 7 sampled residents with a catheter (Resident #147). Failure to follow physician orders for the removal of the foley catheter and to attempt voiding trials may result in an increased risk of catheter associated urinary tract infections (CAUTI) and decreased quality of life. Findings Include: The facility failed to provide a copy of their policy addressing physician orders. During an interview on 06/06/23 at 03:50 p.m., Resident (#147) complained of having a catheter and stated, I want it out. Physician orders on 04/27/2023 at 7:23 a.m., stated, Attempt voiding trial with next scheduled catheter change (5-16-2023). Remove catheter in the morning. Leave out for 4 hours and push fluids. [...]

Inspectors wroteBased on observation, review of facility policy, record review, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 3 residents (Resident #56) observed during insulin administration. Failure to obtain an accurate label for an insulin pen following an order change may result in residents receiving too much/little insulin and/or having a negative reaction.

Inspectors wroteBased on observation, review of facility policy, and staff interview the facility failed to store dietary supplements under safe and sanitary conditions in 2 of 5 medication carts (Riverside Long Hall and [NAME] Short Hall) observed. Failure to remove scoops in dietary supplements may result in contamination of supplements or spread of infection to residents.