Ayer Valley Rehab and Nursing

In the surveyor’s words

From the most serious findings on record at Ayer Valley Rehab and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF580Mar 5, 2024

  Based on observation, interview, record and policy review, the facility failed to notify the Physician/Non Physician Practitioner (NPP: Nurse Practitioner) of changes in condition related to a pressure wound for one Resident (#60) out of a total sample of 26 residents, who was identified to be at risk for skin breakdown. Specifically, the facility staff failed to notify the Physician/NPP when: 1. The Resident developed a pressure injury (PI: localized damage to the skin and/or underlying soft tissue usually over a bony prominence presenting as intact skin) on his/her left hip on 2/6/24. 2. […]

• Actual harm, isolatedF686Mar 5, 2024

  Based on record and policy review, and interview, the facility failed to provide necessary pressure ulcer (PU: localized damage to the skin and/or underlying soft tissue usually over a bony prominence) treatment and services, consistent with professional standards of practice, to promote healing for one Resident (#60), out of a total sample of 26 residents. Specifically, the facility staff failed to: 1. Adequately assess Resident #60's change in skin condition when the Resident was identified to have a PU on his/her left hip. 2. […]

• Actual harm, isolatedF600Sep 27, 2023

  Based on records reviewed, review of facility surveillance camera video footage, and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure he/she was free from abuse from a staff member. Review of the surveillance camera video footage from 08/24/23 during the evening shift, showed Resident #1 pick up a cup containing yellow-tinted liquid off a medication cart, put it up to his/her mouth, Nurse #1 quickly goes over to him/her, grabs the cup of liquid from Resident #1's hand and throws the liquid into Resident #1's face, and Nurse #1 also engaged in a verbal altercation with him/her, the incident was witnessed by another staff member who stepped into intervened. […]

• Actual harm, isolatedF557Jul 5, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was cognitively intact, made his/her own decisions, who resided in a room where he/she occupied and enjoyed having the bed closest to the window, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 06/08/23 at approximately 2:30 P.M., while Resident #1 was off the unit and outside the facility participating in a scheduled smoke break, Unit Manager #1 directed unit staff to change his/her room (which included moving all of his/her personal belongs) to one in which he/she would then occupy the bed closest to the door. […]

• Actual harm, isolatedF580Jun 16, 2022

  Based on observation, interview and record review, the facility failed to ensure staff notified the physician of: (1) A change in the treatment plan, specifically a missed hemodialysis (procedure used to remove waste and fluid from the blood when the kidneys stop working) visit, for one Resident (#205) out of one applicable sampled resident, and (2) A change in condition, specifically a new pressure ulcer, for one Resident (#88) out of three applicable sampled residents. Findings include: 1. Resident #205 was admitted to the facility in June 2022 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . […]