Valley Springs Rehabilitation and Health Center

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 2 (Residents #27, #236,) of 26 sample mix residents reviewed for care plan.

Inspectors wroteBased on observation, interview, record review, and facility document review, it was determined that the facility failed to ensure resident ' s physician orders for a breathing device (bipap) had instructions for monitoring and frequency of use for 1 (Resident #236) of 1 sample mix residents with orders for bi-pap machine and to ensure fall assessments were completed for 1 (Resident #6) of 1 sample mix resident reviewed for fall assessments.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure food stored in the freezer was covered or sealed; manufacturer's instructions were followed; 1of 2 ice machines on B-Hall was maintained in clean and sanitary condition; the kitchen floor and door frames were maintained in good repair and were free of chips, paint peeling, stains and rust; baseboards were secured and were maintained in clean sanitary conditions; and dietary staff washed their hands before handling clean equipment or food items for 2 of 2 meals observed.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure staff maintained hand hygiene during meal service while on the secured unit to prevent cross contamination and to ensure an indwelling catheter was kept out of a resident ' s trash can and was kept off of the floor for 1 (Resident #79) of 2 (Resident #79, #82) sample mix residents with indwelling catheters.

Inspectors wroteBased on observation, interviews, record review, and facility document review, it was determined that the facility failed to ensure a comprehensive assessment accurately reflected a resident ' s status and needs for 1 (Resident #236) of 1 sample mix residents reviewed for comprehensive care plan development.

Inspectors wroteBased on interviews, record review, facility document review, it was determined that the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for 1 (Resident #24) of 2 sample residents reviewed for PASRR, to ensure the resident received the needed care and services in the most appropriate setting.

Inspectors wroteBased on observation, record review, interview, and facility document review, it was determined that the facility failed to ensure fall mats were maintained in good condition for 1 (Resident #82) of 1 sample mix resident whose fall mats were observed. During an observation of Resident #82 on 1/21/25 11:11 AM, this surveyor observed the resident lying in bed on their back at a forty-five (45) degree angle. A fall mat was present on one side of the bed. One side of the bed was against the wall, with a fall mat approximately 6-8 inches away from the other side of the bed. The fall mat was observed to have rips/tears on it. Review of Resident #82's Care plan dated 1/3/2024 noted the resident was at risk for falls related to impaired safety awareness. The resident was documented as having falls on: [...]

Inspectors wroteBased on record review, interview, facility document review, and facility policy review, it was determined the facility failed to ensure necessary care and services were provided related to dementia care, as evidenced by failure to ensure residents were assessed prior to admission to a closed unit to determine if placement on the unit was appropriate for the resident and failure to ensure sufficient staff with training in care of residents with dementia and behaviors were available to provide care to the residents who resided on the closed unit in accordance with the comprehensive assessments and plans of care for 1 (Resident #27) of 7 (Residents #1, #2, #4, #6, #12, #19, and #27 ) case mix residents who had behaviors and resided on the closed unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food stored in the refrigerator and freezer was covered or sealed to prevent potential contamination or freezer burn; kitchen floors were clean; and facial hair was covered. This failed practice had the potential to affect 92 residents who received meal trays from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served at the same time for all residents sitting at the same table for 2 (Residents #18 and #40) of 2 sampled residents to promote dignity and respect.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the State Ombudsman's contact information was visible and made available to all 96 residents residing in the facility.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure pest control devices were removed from 1 of 1 dining room after the devices became saturated with insects.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the environment was as free of accidents and hazards as possible, as evidenced by failure to ensure a bottle of after shave was removed from a bedside table and a razor and a can of shaving cream were removed from a shared bathroom for 1 (Resident #3) of 6 (Residents #3, #41, #59, #61, #72, and #85) sampled residents on the B Hall who needed assistance with shaving as documented on a list provided by Nurse Consultant #2 on 12/19/23 at 2:39 PM and failed to ensure a medication cup was discarded after the morning medication administration to prevent the potential for injury and/or accidents for 6 residents who ambulated independently on the male Secure Unit as documented on a list provided by the Director of Nursing (DON) on 12/21/23 at 10:00 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nutritional interventions were implemented after a significant weight loss occurred to minimize the potential for further weight loss for 1 (Resident #85) of 5 (Residents #26, #41, #72, #74 and #85) sampled residents who had experienced a weight loss of 5 percent (%) or more as documented on a list provided by the Assistant Director of Nursing (ADON) on 12/21/23 at 9:57 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure the blinds in room [ROOM NUMBER] on the A Hall were in good condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure training, assessments, and physician orders were implemented to prevent wheelchair harness injury for 1 (Resident #1) of 1 sampled resident whose neck was caught on the chest harness causing a small red area on his [NAME] apple. The Administrator was notified of the Past IJ (Immediate Jeopardy) on 09/22/22 at 9:36 AM, and the facility failed to ensure scissors were not in the possession of 1 (Resident #51) of 5 (Residents #51, #33, #78, #8 and #39) sampled residents who resided on the Secure Unit to ensure the safety of the residents who were ambulatory and resided on the Secure Unit. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; and 2 of 2 ice machines and 1 of 2 ice scoop holders were maintained in a clean condition to prevent the potential contamination of residents' food or beverages. These failed practices had the potential to affect 77 residents who received meals from the kitchen, (Total Census: 79), as documented on a list provided by the Dietary Manager on 9/22/2022.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advanced Directive was available in the medical record for 2 (Residents #58 and #282) of 2 sampled residents whose records were reviewed for an Advanced Directive. This failed practice had the potential to effect 79 residents at the facility per the Resident Census and Conditions of Residents received from the Director of Nursing (DON) on [DATE].

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment were coded accurately to ensure residents received adequate care for 3 (Residents #33, #48 and #66) of 18 (Residents #1, #8, #17, #19, #26, #30, #31, #33, #37, #45, #48, #51, #56, #58, #66, #76, #78, and #282) sampled residents whose MDS was reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) evaluation process was completed in accordance with the State PASRR process to ensure the resident received appropriate care and services for 4 (Residents #8, #31, #51 and #78) of 4 sampled residents who had a diagnosis of a serious Mental Disorder.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 1 of 2 meals observed. This failed practice had the potential to affect 13 residents on the A Hall (unit), 13 residents on the B Hall, 9 residents on the C hall, 7 residents on the D hall, 14 residents on the E hall, and 3 residents on the F Hall who received meals in their rooms, as documented on a list provided by Dietary Manager on 9/22/2022 at 11:50 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 7 residents who received pureed diets, as documented on the Diet List provided by the Dietary Manager on 9/22/2022.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and implement an appropriate plan of action to correct and identified quality deficiencies cited on the 2019 & 2021 Annual Surveys to monitor, track, and evaluate the effectiveness of accident/hazards and accurately coding the Minimum Data Set (MDS) Plan for their Quality Assurance Corrective Action/Performance Improvement Activities/Plan (QACAPIAP). This failed practice had the potential to affect 79 residents residing in the facility according to the Resident Census and Condition provided by the Director of Nursing (DON) on 9/21/22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff who handled the dirty laundry was wearing personal protective equipment (PPE) to help prevent the potential of cross contamination and spread of infection for 79 residents whose linens are laundered by the facility per the Resident Census received from Director of Nursing (DON) on 9/21/22.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal immunizations were administered to eligible residents and the immunization records were updated in the electronic medical records for 3 (Residents #8, #26 and #51) of 5 (Residents #8, #26, #31, #51 and #56) sampled residents.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure care plans were reviewed and revised after each quarterly assessment or change to accurately reflect resident's needs for 1 (Resident #76) of 1 sampled resident whose care plan was reviewed.