Valley West Health Care Center

Inspectors wroteBased on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 1 sampled resident (# 101) reviewed for abuse and neglect. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to staff a registered nurse (RN) for 8 consecutive hours per day 7 days per week for 4 out of 34 days reviewed for staffing. This placed residents at risk for unmet assessment needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow CDC (Centers for Disease Control and Prevention) Infection Control Guidelines related to Enhanced Barrier Precautions for 13 of 13 sampled resident rooms (#s 3, 7, 8, 12, 13, 14, 17, 21, 22, 23, 24, 29, and 33) reviewed for infection control. This placed residents at risk for exposure to infections and cross contamination.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were offered and received pneumococcal vaccines for 4 of 7 sampled residents (#s 31, 52, 267, and 268) reviewed for vaccines. This places residents at risk for pneumonia.

Inspectors wroteBased on interview and record review it was determined the facility failed to conduct a Significant Change MDS assessment within the required timeframe for 1 of 1 sampled resident (#18) reviewed for hospice. This placed residents at risk for unassessed needs.

Inspectors wroteBased on interview and record review it was determined the facility failed failed to complete a referral for a Level ll PASARR (Pre-admission Screening and Resident Review) for 1 of 2 sampled residents (#18) reviewed for PASARR. This placed residents with a mental health disorder at risk for delayed care, emotional distress related to mental illness and lack of services to attain their highest practicable well-being.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for CBGs and medications for 2 of 8 sampled residents (#s 8 and 218) reviewed for nutrition. This placed residents at risk for ineffective medication regimen.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the care plan related to bathing was followed for 1 of 1 sampled resident (#16) reviewed for accidents. This placed residents at risk for injuries.

Inspectors wroteBased on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 5 sampled residents (#35) reviewed for unnecessary medications. This placed residents at risk unmet needs.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure residents were treated with dignity related to dining needs for 1 of 2 sampled dining areas reviewed for dining. This placed residents at risk for lack of a dignified dining experience.

Inspectors wroteBased on interview and record review it was determine the facility failed to transmit resident assessments in the required timeframe for 5 of 5 residents (#s 18, 47, 54, 55, and 56) reviewed for late assessments.

Inspectors wrote2. Resident 168 was admitted to the facility in 2023 with a diagnosis of heart failure. A 11/20/23 admission MDS and associated CAAs revealed Resident 168 was assessed to have cognitive impairment. A 12/5/23 Incident Summary revealed on 12/5/23 Resident 168 alleged on the night shift of 12/4/23 she/he was restrained and two CNAs of the opposite gender messed with her/him. The facility investigated the incident and was not able to support the resident's allegations. Progress Notes from 12/5/23 through 12/11/23 did not include the staff monitored Resident 168 to ensure she/he did not have psychosocial outcome related to her/his allegations of abuse. On 2/8/24 at 10:43 AM Staff 2 (DNS) stated if a resident reported abuse, even when the allegation was not supported, staff were to monitor the resident for 72 hours to ensure the resident felt safe. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 4 sampled residents (#33) and 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident food preferences were honored for 1 of 1 facility reviewed. This place residents at risk for lack of honored preferences.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement consistent use of PPE in 2 of 5 halls and failed to perform hand hygiene when required while assisting dependent residents to eat in 1 of 2 dining rooms. This placed residents at risk for communicable diseases and spread of infection.

Inspectors wroteBased on interview and record review it was determined the facility failed to notify the physician for a change of condition for 1 of 1 sampled resident (#33) reviewed for change of condition. This placed residents at risk for delayed treatment.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a comprehensive care plan was developed for 1 of 6 sampled residents (#50) reviewed for vision and medications. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to involve residents in the care planning process and revise care plan interventions for 3 of 10 sampled residents (#s 8, 50 and 168) reviewed for care plans, restraints and medications. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#317) reviewed for ADLs. This placed resident at risk for lack of personal hygiene.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assist in vision care needs for 1 of 3 sampled residents (#50) reviewed for vision. This placed residents at risk for a decline in leisure activities.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement physician orders related to a pressure ulcer for 1 of 2 sampled residents (#8) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a restorative program to prevent further decline in range of motion and to apply devices as ordered for 3 of 3 sampled residents (#s 17, 38, and 50) reviewed for ROM. This placed residents at risk for decline in their range of motion abilities.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders to maintain healthy parameters of nutritional status and monitor for weight loss for 2 of 4 residents (#s 24 and 61) reviewed for hydration and nutrition. This placed residents at risk for weight loss.

Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#40) reviewed for medications. This placed residents at risk for ineffective medications and medication side effects.

Inspectors wroteBased on interview and record review it was determined the facility failed to monitor the use of psychotropic medications for 1 of 5 sampled residents (#40) reviewed for medications. This placed residents at risk for ineffective medications and medication side effects.

Inspectors wrote2. The Life Care Centers of America Policy and Procedure: Lab Procedures and Diagnostics for Collecting a Stool Specimen dated 9/20/23 indicated the following: The facility will provide Collecting a Stool Specimen in accordance with professional standards of practice, as outlined by [NAME] through the procedure (helps nursing staff achieve clinical excellence, with access to the latest evidence-based clinical information). Because it it's possible to obtain stool specimens on demand, proper collection requires careful patient instructions to ensure an uncontaminated specimen. Special Considerations: Place stool specimens in a refrigerator used only for specimens. If testing for Clostridioides difficle (C. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure menus were followed for 2 of 5 sampled residents (#s 24 and 33) observed during dining observations. This placed residents at risk for lack of honored preferences and nutrition.

Inspectors wroteBased on observation, interview and record review it was determine the facility failed to ensure an ordered diet texture was provided as ordered for 1 of 3 sampled residents (#24) reviewed for nutrition. This placed residents at risk for unmet dietary needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 2 of 2 sampled residents (#s 11 and 42) reviewed for medication administration. Resident 11 was administered an extended release antihypertensive medication in an inappropriate manner placing her/him at risk for clinical complications. Alteration of the medication's absorption properties can cause serious side effects up to and including fatal overdose. This failure was determined to be an immediate jeopardy situation.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters of hydration and nutrition status for 5 of 9 sampled residents (#s 7, 16, 20, 54 and 259) reviewed for hydration and nutrition. Resident 7 experienced a severe weight loss.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the DCSDR (Direct Care Staff Daily Reports) were complete for 12 of 18 days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain adequate room temperatures and clean and sanitary conditions on 2 of 2 halls (North and South) reviewed for environment. This placed residents at risk for lack of a clean and comfortable environment.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 14, 15, 16 and 19) reviewed for staffing. This placed residents at risk for a lack of competent staff.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 34 medication administration opportunities with 4 errors. The medication error rate was 11.76%. This placed residents at risk for decreased medication efficacy and/or adverse side effects.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to properly store and monitor food in 1 of 2 resident refrigerators and provide a clean exhaust hood for 1 of 1 kitchen. This placed residents at risk for an unclean preparation area and foodborne illness.

Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 4 randomly selected staff members (#s 15, 16 and 19) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure care was provided in a manner that maintained and promoted dignity for 1 of 1 sampled resident (#20) reviewed for dignity. This placed residents at risk for receiving care that did not promote their dignity.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were included in care planning for 1 of 2 sampled residents (#20) reviewed for care planning. This placed residents at risk for not being involved in the care planning process.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure preferences were honored for 1 of 1 sampled resident (#30) reviewed for choices. This placed residents at risk for lack of support for preferences.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from verbal and physical abuse for 1 of 3 sampled residents (#52) reviewed for abuse. This placed resident at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to report potential abuse to the state agency for 1 of 3 sampled residents (#52) reviewed for abuse. This placed resident at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete thorough investigations related to abuse for 3 of 3 sampled residents (#s 19, 43 and 52) reviewed for abuse investigations. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to accurately code assessments for skin conditions and mood and behaviors for 3 of 11 sampled residents (#s 7, 26 and 42) reviewed for nutrition, pain and ADLs. This placed residents at risk for inaccurate assessments.

Inspectors wroteBased on interview and record review it was determined the facility failed to develop and implement comprehensive care plans for 3 of 6 sampled residents (#s 14, 18 and 54) reviewed for accidents, behavior, and pressure injury. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to revise care plans for 2 of 3 sampled residents (#s 16 and 42) reviewed for care planning and hospitalization. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide showers and personal hygiene for dependent residents for 2 of 6 sampled residents (#s 36 and 40) reviewed for ADLs. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to monitor edema for 1 of 1 sampled resident (#16) reviewed for oxygen. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure skin and wounds were accurately and routinely assessed for healing for 2 of 4 sampled residents (#s 18 and 260) reviewed for pressure ulcers. This placed residents at risk for new and worsening pressure ulcers.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide adequate foot care for 3 of 5 sampled residents (#s 26, 42 and 47) reviewed for ADLs. This placed residents at risk for increased foot problems.

Inspectors wroteBased on observation, interview and record reviewed it was determined the facility failed to provide ROM services for 3 of 3 sampled residents (#s 23, 43 and 40) reviewed for ROM. This placed residents at risk for decreased ROM.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure care planned interventions and facility smoking policies were followed, and investigations were thorough for 3 of 4 sampled residents (#s 16, 40 and 54) reviewed for accidents. This placed residents at risk for injuries.

Inspectors wrote2. Resident 162 was admitted to the facility in 6/2022 with diagnoses including chronic heart failure, kidney disease and COVID-19. On [DATE] at 9:49 AM a Communication with Physician included the following: Situation: The resident's oxygen (O2) saturation (sat) was 69 percent on two liters via nasal cannula. Background: The resident with active COVID-19. Assessment (RN)/Appearance (LPN): Resident was lying flat and coughing when O2 sat was 69%. This LN raised head up to 90 degrees and increased O2 to 3L. O2 sat increased to 72%. O2 was then increased to 4L and resident's O2 sat increased to 80%. O2 was then increased to 5L and resident began to sat between 93-95%. Resident's lungs continue to be congested with adventitious lung sounds noted in all lobes. Resident has no orders for medications to assist with breathing. On [DATE] at 2:59 PM an Orders Administration Note indicated: [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to manage residents' pain for 1 of 2 sampled residents (#43) reviewed for pain. This placed residents at risk for unmanaged pain.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was not given psychotropic medications without an appropriate diagnoses and adequate monitoring for 1 of 5 sampled residents (#42) reviewed for medications. This placed residents at risk for receiving unnecessary medications.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure an effective system for resident food preferences for 1 of 2 sampled residents (#40) reviewed for food . This placed residents at risk for meal prefererences not being honored.