Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Valley Health And Rehab during CMS and state inspections, most recent first.
A dependent resident admitted post-surgery with intact but vulnerable skin and MASD risk developed significant bilateral buttock MASD and a sacral pressure injury that progressed from deep tissue injury to Stage III and then to a large unstageable ulcer with odor and purulent drainage. Facility records showed incomplete and missing weekly skin/wound assessments during the period when the wound worsened, despite a care plan calling for skin evaluations, turning/repositioning, CNA skin inspections, and monitoring of nutrition. Staff interviews revealed they were frustrated by the resident’s anxiety and behaviors, reported the sacral wound as facility-acquired, acknowledged the resident became obtunded on an intense opioid regimen, and stated they were unaware of excessive fluid intake and could not explain why the worsening wound and infection were not recognized or reported before the resident required hospital transfer for a severe sacral decubitus ulcer with associated infection.
Surveyors found that kitchen staff failed to properly label and date multiple food items stored in the walk-in cooler, including slimy sliced tomatoes, ground meat, sliced ham, roast beef, cheese, and strawberries. Staff reported that they sometimes picked moldy strawberries out of shipments and that moldy dinner rolls had been served and then collected from residents. These practices did not follow the facility’s written policy requiring labeling, dating, and monitoring of refrigerated foods so they are used by their use-by date or discarded, placing all residents at risk for foodborne illness.
The facility failed to provide meaningful, resident-centered activities for multiple dementia residents in the memory care unit, resulting in individuals sitting idle in dining and common areas, staring at blank or inappropriate televisions, sleeping in chairs, or wandering hallways without engagement. Activity sessions were canceled or not implemented as scheduled, and when paper activities like word searches were offered, only a few residents participated while others received no assistance, including a resident who repeatedly requested glasses and another who did not speak English. Sitters did not help residents with activities, and an activity staff member spent time on a computer and left the unit for other duties. Staff interviews revealed that management directed the limitation of music and physical activities, that residents were often left in bed because it was easier for staff, that floor staff did not conduct activities in the absence of the activity staff, and that the posted activity calendar, which included exercise, trivia, book club, and weekend "Resident Choice Day," was frequently not followed despite a policy requiring meaningful activities tailored to dementia residents.
A resident with a documented history of opioid-induced constipation and prior fecal impaction was admitted from the hospital, where providers had noted difficulty balancing opioid use and constipation medications. On admission, facility documentation characterized the resident as having normal stool and rarely needing laxatives. Over the following weeks, bowel records showed multiple days without a bowel movement, yet the MAR reflected no scheduled or PRN constipation medications given. Nursing notes documented no constipation despite absent bowel sounds, while subsequent hospital imaging revealed an extensive rectal stool burden concerning for stercoral colitis. Staff interviews confirmed that the prolonged absence of bowel movements was not reported, the resident received no PRN bowel medications, and there was no specific bowel and bladder management policy.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
The facility failed to serve lunch at its scheduled times, with trays on one unit being delivered 36–47 minutes late on multiple days, despite a written schedule specifying earlier service. A resident on that unit experienced repeated delays, with a family member reporting that meals were often late and that the resident was not allowed to lie down until after lunch, causing frustration when lunch arrived significantly behind schedule and was then refused. Staff interviews confirmed that meals had been running late more frequently, citing short staffing in the kitchen, training of a new cook, and the time required to dish up and pass trays, in contrast to the facility’s policy requiring three daily meals without extensive time lapses.
Surveyors identified a failure to store food according to professional standards when they observed multiple open and prepared food items in the walk-in freezer and refrigerator without labels or dates, including an open bag of French fries, cut tomatoes and onion wrapped in cellophane, and a half-empty pan of red Jello. The dietary supervisor reported that staff are instructed to check received and expiration dates, label and date all open and cut items, and use a posted "Use by Date Guide" as a reminder, and facility policy requires labeling, dating, monitoring refrigerated foods, and keeping foods covered or in tight containers.
Insufficient staffing on the Memory Care Unit resulted in residents not receiving needed ADL care, supervision, and meal assistance. Staff reported being unable to complete required tasks, often skipping baths and showers, and residents were observed unkempt and without proper support. Facility records confirmed multiple days with staffing below assessed needs, directly impacting resident care and safety.
A staff member was found to have engaged in verbally abusive behavior toward vulnerable residents in a secure memory care unit, as reported by another employee and confirmed through interviews. The incident involved yelling at residents during a night shift, with prior negative verbal interactions also substantiated. Residents were assessed for distress following the event, but no acute distress was observed.
Ten residents who required assistance with ADLs did not receive regular showers or adequate hygiene support, as evidenced by observations of unkempt appearance, resident and family complaints, and gaps in shower logs. Residents with conditions such as decreased mobility, Parkinson's disease, and stroke were not consistently assisted with bathing as outlined in their care plans, and facility documentation showed missed or delayed showers despite identified concerns.
The facility did not complete thorough investigations into staff-to-resident verbal abuse and neglect allegations involving two residents, failing to monitor residents, implement documented interventions, or interview other residents and staff. Documentation was incomplete for multiple incidents, and required investigative steps were not followed according to facility policy.
A resident with Alzheimer's disease and severe cognitive impairment exhibited frequent distress, behavioral symptoms, and functional decline. Staff did not implement care-planned interventions such as diversional activities, one-to-one support, or prompt redirection, and failed to provide adequate supervision or monitor interactions with others. Documentation showed minimal activity participation and incomplete mood and behavior assessments, despite the resident's ongoing distress and behavioral issues.
Staff did not consistently use Enhanced Barrier Precautions (EBP) or appropriate PPE when providing high-contact care to two residents with urinary catheters. In both cases, staff either failed to don PPE or only wore gloves despite clear facility policy and signage requiring EBP for residents with indwelling devices during transfers and toileting.
A resident was transferred or discharged without the facility ensuring that their needs and preferences were met, and without adequate preparation for a safe transition.
The facility did not complete a thorough investigation after a staff member was witnessed verbally abusing a resident. Required 72-hour monitoring and emotional support for the affected resident were not documented, and no additional resident interviews were conducted to rule out further abuse concerns, contrary to facility policy.
A resident at risk for nutritional deficits experienced severe weight loss due to inadequate monitoring by the facility. Despite being identified as at risk due to recent weight loss and comorbidities, the resident's weight was not recorded for over a month, resulting in a 25.5-pound loss. The facility's policy required weekly weights for such residents, which was not followed.
The facility failed to maintain safe and palatable food temperatures for residents eating in their rooms. A resident reported receiving cold food, and another mentioned a specific instance of a cold taco. Staff confirmed that food was not kept at the required temperature, with a pancake served at only 100.7°F, below the mandated 135°F. The facility's policy requires hot food to be served at a minimum of 135°F, which was not followed.
A facility failed to ensure a POLST form for a resident was completed with the necessary signature from the resident or their decision-maker. The POLST form, which indicated preferences such as DNR and comfort measures only, lacked a documented signature or printed name. Facility policy requires that advance directives and POLST forms be documented and reviewed, but this was not adhered to in this case.
Failure to Prevent and Manage Pressure Ulcer Leading to Severe Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate prevention and treatment of pressure ulcers and to complete and document required skin and wound assessments for a dependent resident. The resident was admitted from a hospital with red skin on the right elbow, a left neck surgical laminectomy site, and a left shin abrasion, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and had a Foley catheter. Within six days of admission, weekly wound documentation showed the resident had developed bilateral buttock moisture-associated skin damage (MASD) of significant size. The resident was then hospitalized for confusion and hyponatremia, and hospital wound care documented a deep tissue pressure injury to the sacrum that evolved into a Stage III pressure injury with yeast. When the resident returned to the facility, the facility’s readmit screener documented MASD to the buttocks and a yeast rash to the buttocks and groin, but no sacral pressure injury. Subsequent facility wound documentation showed that a few days after readmission, the resident had scattered ulcerations with MASD to the buttocks and a Stage III pressure ulcer to the right medial lower buttock, and that orders for treatment were requested from the physician. By the following week, the weekly wound observation tool documented that the Stage III bilateral buttock wounds had merged into one large unstageable pressure ulcer with odor and moderate purulent drainage, indicating potential infection. During this same period, there were no documented skin/wound assessments for the week leading up to the resident’s transfer back to the hospital, and a staff member later stated she did not know where the assessments were or why they were not done, and could not explain why no one reported that the wound was worsening. The care plan listed multiple skin integrity problems and interventions, including skin evaluations, routine turning and repositioning, CNA skin inspections with routine care, monitoring nutrition, and weekly nurse skin evaluations, but did not specify task frequency for some interventions. Interviews further described staff awareness and handling of the resident’s condition and behaviors. A family member reported that staff were frequently frustrated by the resident’s constant need for attention and anxiety, and that he repeatedly educated management about the resident’s high anxiety and hyperfocus, and did not understand how staff could report spending so much time with the resident yet not recognize how sick he was with infection. A staff member stated the sacral wound was facility-acquired, that the resident became obtunded related to opioids, and that she was unaware of the resident’s excessive water intake until after a hospital stay. Another staff member who completed a readmission history and physical found the resident febrile, with therapy unable to mobilize him due to pain, and described the resident as heavily sedated on an intense pain regimen that predated his stay. This staff member stated there were many opportunities for improvement in nursing assessments and that the facility could not handle the resident’s complex psychiatric and pain needs. Ultimately, the resident was transferred to the hospital with a large sacral decubitus wound with purulent tissue, surrounding cellulitis, and radiologic evidence of a severe sacral ulcer with erosion nearly to the coccyx and associated abscess and necrotizing soft tissue infection.
Improper Labeling, Dating, and Handling of Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when, during an observation of the walk-in cooler, multiple food items were found undated or unlabeled, contrary to the facility’s Food Safety Requirements policy. Specifically, two zip-lock bags of slimy, sliced tomatoes were not dated; a gallon zip-lock bag of ground meat was not labeled with the food type or date; and separate gallon zip-lock bags of sliced ham, sliced roast beef, and sliced cheese were all undated. In addition, a cup of sliced strawberries had no date. Staff interviews revealed that kitchen staff had observed mold on strawberries upon delivery and would usually attempt to pick out the molded strawberries, and another staff member acknowledged awareness of ongoing dating issues with refrigerated foods. A further interview indicated that moldy dinner rolls had been served on one occasion, prompting staff to retrieve the rolls from residents after service. The facility’s written policy required labeling, dating, and monitoring refrigerated food, including leftovers, so it would be used by its use-by date or frozen/discarded, but these requirements were not followed, placing all residents at risk for foodborne illnesses. No specific residents or their medical histories were identified in the report; the deficiency was described as affecting all residents through improper food labeling, dating, and handling practices in the kitchen and walk-in cooler.
Failure to Provide Meaningful Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, resident-centered activities to meet the needs of multiple residents with dementia in the memory care unit. Surveyors observed residents sitting in dining and common areas without any activities, including a resident with a BIMS score of 0 repeatedly scratching her arms while staring at a turned-off television, and another resident wandering the unit and running into walls. On another observation, the scheduled activities were canceled due to weather, and the activity staff member present was working on care plans on a computer while residents sat with newsletters in front of them, many staring at the floor or sleeping. Only some residents participated in the offered activities, while others, including residents with severely and moderately impaired memory, did not participate and were not engaged. During the same observation period, residents were given a word search activity, but only a few actively worked on it. Sitters, who were present to watch and redirect residents, sat at the tables and did not attempt to assist residents with the activity. One resident repeatedly stated she needed her glasses to see the paper, but no staff obtained her glasses. A resident who did not speak English sat staring down the hall without engagement, and another resident with severe cognitive impairment wandered the hall. The activity staff member stated she had other duties in another unit and left, and later that evening, surveyors observed one resident sleeping in a recliner and another staring at a wall while cartoons played on the television. Interviews with staff revealed that activities in the memory care unit were limited and often not implemented as scheduled. The activity staff member reported she was instructed by management to avoid music and physical activities because staff believed these would cause residents to become agitated, and that she was told to limit activities to calming options only. She also stated that residents were often left in bed and not taken to activities because it was easier for staff, and that floor staff did not provide activities when she was not present, preferring residents to sit quietly. Other staff confirmed that activities usually did not occur in the memory care unit, that activities observed during the survey were a show for surveyors, and that the activity calendar was not followed. The memory care activity calendar showed “Resident Choice Day” on all weekends and listed trivia, exercise/stretching, and book club on weekdays, while the facility’s activities policy required activities to enhance well-being, physical activity, cognition, and to provide meaningful activities for residents with dementia.
Failure to Monitor and Treat Constipation in Resident With Opioid-Induced Constipation History
Penalty
Summary
The facility failed to monitor and manage constipation for a resident with a known history of opioid-induced constipation and prior use of constipation medications. Hospital records showed the resident had been admitted with a 9.6 cm fecal impaction and that the hospital physician documented the resident could go up to five days without a bowel movement, likely due to opioid use, and was working on balancing opioid-induced constipation with constipation medications. Upon admission to the facility, the Admit/Readmit Screener documented that the resident had normal formed stool and rarely or never depended on laxatives, despite this history. Facility bowel documentation later showed gaps in bowel movements, including no bowel movement for several days. Review of the Medication Administration Record for March and April showed the resident did not receive any scheduled or PRN constipation medications during the stay. Bowel documentation indicated no bowel movement from 3/29 to 4/3, followed by diarrhea on 4/4 and a putty-like stool on 4/5. A nursing progress note on 4/6 documented a flat, non-tender abdomen with no bowel sounds and no constipation, while hospital records from the same date, after readmission, showed an extensive stool burden distending the rectum to 8.8 cm with findings concerning for stercoral colitis. Staff interviews revealed that no one reported the resident had gone six days without a bowel movement, the resident had gone without any PRN bowel medications, and the facility did not have a policy specific to bowel and bladder management.
Failure to Perform Hand Hygiene During Wound and Skin Care
Penalty
Summary
Facility staff failed to ensure proper hand hygiene during care of a resident with suspected infected lower extremities. During an observation, two staff members entered the room of a resident who had reported weeping and hot lower legs. One staff member removed the TED hose from the resident’s left leg, noted that the leg was hot to the touch and weeping edema fluid, then moved directly to the right leg, removed the TED hose, and assessed that leg without changing gloves or performing hand hygiene between contact with the weeping left leg and the intact right leg. This same staff member later stated she believed she had completed all hand hygiene opportunities but realized, when questioned, that she had moved from one leg to the other without performing hand hygiene. The resident had been started on Cipro for cellulitis on the morning of the observation. A second staff member returned to the room with new TED hose and socks, donned gloves, and assisted with applying the TED hose. This staff member applied TED hose to the resident’s left leg, observed weeping fluid from the skin, and then proceeded to clean up the room while still wearing the same contaminated gloves. While gloved, she touched the resident’s food on the bedside table, handled the resident’s pillow and placed it on the chair where the resident was sitting, and put her gloved hand into her clothing pocket to turn off her ringing cell phone. She did not perform hand hygiene or change gloves after contact with bodily fluids and before touching other items in the room. After leaving the room, she stated she had not thought about performing hand hygiene after finishing application of the TED hose. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects, when moving from a contaminated site to a clean body site during resident care, and after handling items potentially contaminated with blood or bodily fluids.
Late Meal Service and Resident Frustration Due to Delayed Lunch Trays
Penalty
Summary
The deficiency involves the facility’s failure to provide meals at the scheduled times established by its own meal schedule, resulting in resident frustration. The facility’s posted meal schedule indicated that lunch trays for Birch Hall residents were to be delivered at 12:20 p.m. However, observations on two separate days showed that lunch trays were passed significantly later than scheduled: at 12:56 p.m. on one day (36 minutes late) and at 1:07 p.m. on another day (47 minutes late). On one of these days, the last lunch tray to Birch Hall was still being delivered at 1:14 p.m. Staff interviews confirmed that meals were sometimes late, that residents often sat waiting in the dining room for extended periods, and that meals had been served late more frequently recently. One resident, identified as resident #31, was directly affected by these delays. On one day, the resident’s lunch tray was delivered to his room at 12:56 p.m., and a family member (NF1) reported that lunch meals were often served late and that “you get used to it over time.” On another day, NF1 approached staff to ask where the lunch meal was, stating that the resident wanted to lie down but had been told he could not do so until after lunch, and that he was not happy lunch was so late. When the tray was finally delivered at 1:07 p.m., the resident expressed dissatisfaction with the meal, and NF1 returned the tray and ordered an alternative. Staff interviews attributed the late meals to factors such as training a new cook, being short two kitchen staff members, and the time it took staff to dish up and pass the meals, despite a facility policy stating that residents would receive at least three meals daily without extensive time lapses between meals.
Failure to Label and Date Open and Prepared Food Items in Dietary Storage
Penalty
Summary
Surveyors found that the facility failed to store food in a sanitary manner in the dietary department. During an observation of the walk-in coolers, an open bag of French fries was found in the freezer with no label or date. In the refrigerator, two halves of a tomato wrapped in cellophane, half of an onion wrapped in cellophane, and a large pan of half-empty red Jello were also observed without any labels or dates. These items were not labeled or dated as required by facility policy. In an interview, the dietary staff member responsible for directing dietary staff stated that she instructs staff to check the received date and expiration date when they open an item and to place a label and date on any open items and anything cut and wrapped in cellophane. She reported that she continues to remind staff to label open items and indicated that a "Use by Date Guide" was posted on the outside of the refrigerator door as a reminder of the rules for dating open items. Review of the facility’s Food Safety Requirements policy confirmed that food is to be stored in accordance with professional standards, including labeling, dating, and monitoring refrigerated food such as leftovers so it is used by its use-by date or discarded, and keeping foods covered or in tight containers.
Insufficient Staffing Leads to Inadequate Resident Care and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff on the Memory Care Unit to meet the needs of residents, resulting in inadequate monitoring, assistance with activities of daily living (ADLs), meal assistance, and abuse prevention. Multiple observations and staff interviews revealed that residents were left unsupervised, including those requiring one-to-one supervision due to disruptive behaviors. Staff reported being unable to complete all required tasks during their shifts, often skipping baths and showers due to time constraints and insufficient staffing. Residents were observed wearing the same clothing over consecutive days, appearing unkempt, and not receiving scheduled or needed bathing services. Further observations documented residents without appropriate assistance during meals, such as a resident eating with her fingers and pouring water onto her plate without staff intervention. Staff consistently reported that the lack of adequate staffing made it difficult to provide necessary care, particularly for bathing and supervision. The facility's own records confirmed that on several days, staffing levels were below what was identified as necessary in the facility assessment, directly impacting the quality of care provided to residents. Documentation and interviews indicated that the facility had identified staffing as an ongoing issue, particularly affecting the provision of ADL care and resident supervision. The lack of staff also affected the ability to provide activities and ensure resident safety, with staff expressing concerns about their inability to protect residents and complete essential care tasks. The deficiency was supported by observations, interviews, and record reviews, all indicating a pattern of insufficient staffing leading to unmet resident needs.
Verbal Abuse of Vulnerable Residents in Memory Care Unit
Penalty
Summary
A staff member on the memory care unit was reported to have engaged in verbally abusive behavior toward residents. The incident was initially brought to attention when a CNA reported, via text message, that an employee had been yelling at residents during the night shift. The report did not specify which residents were involved or the exact language used, but all residents in the memory care unit were identified as vulnerable. Subsequent interviews confirmed that the staff member in question had previously demonstrated negative verbal interactions with residents. The facility's investigation substantiated the allegation of verbal abuse, confirming that the staff member had engaged in inappropriate verbal conduct toward residents on more than one occasion. At the time of the incident, residents were assessed for signs of distress or behavioral changes, but no acute distress was noted. The deficiency centers on the occurrence of verbal abuse directed at vulnerable residents in the secure memory care unit by a staff member.
Failure to Provide Regular Showers and ADL Assistance
Penalty
Summary
The facility failed to provide regular showers and adequate assistance with activities of daily living (ADLs) for 10 out of 18 sampled residents who were unable to perform these tasks independently. Observations and interviews revealed that multiple residents appeared unkempt, with oily or matted hair, and expressed feelings of being dirty or neglected due to missed or infrequent bathing. Shower logs confirmed significant gaps between baths, with some residents going up to 16 days or more without a shower, and in one case, a resident did not receive any bath in a 30-day period. Residents' care plans consistently indicated the need for staff assistance with bathing due to various medical conditions such as decreased mobility, Parkinson's disease, stroke, and memory deficits. Several residents and their families reported concerns about hygiene and the lack of regular bathing. For example, one resident stated that staff refused to help with baths, resulting in missed showers and feelings of being dirty. Another resident's family contacted the facility to express concern about the resident's matted hair and infrequent bathing. Residents' care plans outlined specific interventions, such as offering bed baths if showers were declined and notifying nursing staff if both were refused, but documentation and interviews indicated these interventions were not consistently implemented. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Performance Improvement Project (PIP) action plan identified issues with staffing, adherence to bathing schedules, and documentation as root causes for the deficiency. Despite recognizing the problem, the facility did not follow through with corrective actions, as evidenced by ongoing missed or delayed showers for multiple residents. Facility policy required that care and services for ADLs, including bathing, be provided based on comprehensive assessment and resident needs, but this standard was not met for the affected residents.
Failure to Complete Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of staff-to-resident verbal abuse and neglect involving two residents. Specifically, the facility did not complete resident monitoring, did not implement interventions that were identified and documented in the incident reports, and did not interview other residents to determine if additional individuals were affected. Documentation for several incidents was incomplete, lacking summaries, evidence of staff education, and records of monitoring activities such as bathing logs or audits. Interviews with staff revealed that investigation folders had not been fully reviewed and that the investigations were still in progress, despite being part of a plan of correction from a previous complaint survey. The facility's own policy requires comprehensive investigation procedures, including reporting, analysis, staff training, and monitoring, but these steps were not documented or carried out as required for the incidents in question.
Failure to Implement Dementia Care Interventions and Supervision
Penalty
Summary
The facility failed to provide appropriate services, treatment, and interventions for a resident diagnosed with Alzheimer's disease and dementia, who exhibited significant cognitive and functional decline. The resident displayed frequent physical and verbal behaviors, including crying, yelling, wandering, and making statements indicating pain, fear, and distress. Despite these behaviors, staff did not implement the care-planned interventions such as providing diversional activities, one-to-one support, or prompt redirection when the resident was upset. Observations showed the resident calling out for help, expressing fear, and making statements about not wanting to live, without staff intervention or support. Interviews with staff revealed that the resident required constant supervision and had a history of altercations with other residents. Staff acknowledged that there was insufficient supervision and that activities for dementia care were lacking or only recently initiated. Documentation showed that the resident participated in very few activities over a two-month period, despite care plan interventions specifying the need for engagement in activities of interest and avoidance of overstimulation. Staff also failed to monitor and intervene during verbal altercations between residents, as required by the care plan. Review of the resident's health records and Minimum Data Set (MDS) assessments indicated severe cognitive impairment, increased behavioral symptoms, and a decline in functional abilities. The resident was unable to complete mood interviews, and staff assessments were either incomplete or blank. The care plan identified the resident as being at risk for verbal abuse from others due to her behaviors, yet the documented interventions were not consistently implemented, resulting in unaddressed distress and behavioral symptoms.
Failure to Implement Enhanced Barrier Precautions for Residents with Catheters
Penalty
Summary
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters, as required by facility policy. During observations, one staff member was seen leaving a resident's room after assisting with a transfer using a mechanical lift, without donning any personal protective equipment (PPE). The resident had a catheter in place, and there was no PPE caddy available outside the room. The staff member admitted to not using PPE and stated she intended to retrieve supplies afterward. The resident confirmed that PPE was not always used during catheter care and noted that PPE supplies had previously been available but were removed, leading to more relaxed practices among staff. In another instance, a staff member entered a different resident's room, which had signage and a PPE caddy indicating the need for EBP, but did not don PPE before assisting the resident, who also had a catheter, with a transfer to the toilet. The staff member only wore gloves and stated she had just been informed that day about the requirement for PPE use with catheters. Interviews with other staff confirmed that EBP should be used for residents with wounds, catheters, or multidrug-resistant organisms during high-contact care tasks, such as transferring and toileting. Review of the facility's policy confirmed these requirements, but observations and interviews demonstrated inconsistent adherence.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. This deficiency was identified based on observations and documentation showing that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not fully prepared for a safe transition to the next care setting.
Failure to Complete Thorough Abuse Investigation and Resident Monitoring
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident of staff-to-resident verbal abuse witnessed by several management staff. Although the staff member involved was immediately removed from the facility, the investigation documentation indicated that the resident was to be placed on every-shift monitoring for 72 hours and provided with one-on-one emotional support. However, review of the resident's nursing progress notes, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the 72 hours after the incident revealed only a single progress note two days post-incident, which described the resident as somnolent and refusing some care, with no interventions noted for these behavioral changes. There was no documentation of the required monitoring or emotional support, and the MAR and TAR did not reflect the monitoring order. Additionally, the facility did not conduct interviews or assessments with other residents to determine if there were further concerns of abuse by the same staff member, as required by facility policy. Staff interviews confirmed that no additional resident interviews were performed, and all investigation materials were limited to the file provided. The facility's policy mandates identifying and interviewing all involved persons and providing emotional support to affected residents, but these steps were not completed in this case.
Failure to Monitor Resident's Weight Leads to Severe Weight Loss
Penalty
Summary
The facility failed to adequately monitor a resident at risk for nutritional deficits, leading to severe weight loss. A staff member indicated that CNAs were responsible for checking the EHR to determine which residents needed to be weighed, with varying frequencies such as monthly, weekly, or daily. However, there was a lapse in monitoring as the resident did not have weights recorded from late September to early November, during which time the resident experienced a significant weight loss of 25.5 pounds. The resident, who was already at risk due to recent weight loss, inadequate food intake, and comorbidities including wounds, was not weighed according to the facility's policy for residents with weight loss, which required weekly monitoring. The resident expressed concerns about his weight loss and mentioned that he had only recently started receiving daily weights to assess the need for a medication that increased urination. Despite the resident's thin appearance and his report of weight loss, the facility did not ensure consistent weight monitoring. A staff member acknowledged the oversight in obtaining regular weights and noted that the resident's nutrition assessment was updated in November, but by then, the resident had already experienced severe weight loss. The facility's policy required weekly weights for residents with weight loss, which was not adhered to in this case.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe and palatable temperatures for food served to residents in their rooms, affecting three of the nineteen sampled residents. Resident #18 reported that their food was cold upon arrival in their room. Resident #3, who ate all meals in their room, also complained about the food being cold and unappetizing, mentioning a specific instance where a taco was served cold. Resident #13, who ate meals both in their room and the dining room, stated that breakfast served in their room was not warm enough. These residents expressed dissatisfaction with the temperature and quality of the food served. Observations and interviews with staff revealed that food was cooked and held at 135 degrees Fahrenheit in a steam table before being served. However, meals for residents eating in their rooms were left in the steam table until after dining room meals were served, leading to a delay. Staff member F confirmed that the temperature of a pancake served to resident #18 was only 100.7 degrees Fahrenheit, below the required 135 degrees Fahrenheit. The facility's policy mandates that hot food items must be cooked, held, and served at a minimum of 135 degrees Fahrenheit, which was not adhered to in these instances.
Incomplete POLST Form Lacks Required Signature
Penalty
Summary
The facility failed to ensure that a POLST form for one of the sampled residents was completed with the necessary signature from the resident or their decision-maker. During an interview, a staff member explained that residents or their representatives are asked about their advance directives upon admission, and these directives are reviewed during the initial care conference. However, a review of the electronic medical record for the resident in question revealed that the POLST form lacked a documented signature or printed name of the patient or decision-maker, despite indicating preferences such as DNR, comfort measures only, and no artificial nutrition by tube. The facility's policy requires that advance directives and POLST forms be documented in a prominent part of the resident's medical record and reviewed periodically. The policy also mandates staff training on these procedures. However, the resident's care plan and the facility's policy both emphasize the importance of having a signed POLST form, which was not adhered to in this case. The absence of a signature on the POLST form indicates a failure to comply with the facility's procedures and the legal requirements for validating such documents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Living Centre | 18.8 mi | — | 5 | 0 |
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