Chosen Valley Care Center

In the surveyor’s words

From the most serious findings on record at Chosen Valley Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Dec 1, 2022

  Based on interview and document review, the facility failed to follow its procedure for ensuring an order had been received after laboratory testing for 1 of 3 residents (R1) reviewed for Coumadin/Warfarin (an anticoagulant) use, this failure resulted in seven missed doses and sub-optimal lab results which placed R1 at risk for embolism formation (an abnormal clot in the circulatory system). This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on 11/21/22, when a licensed practical nurse (LPN)-A failed to follow a prompt in R1's Medication Administration Record (MAR) to contact the clinic if an order for Coumadin dosing had not been received after laboratory test results had been sent. […]

• No harm, potential for more than minimal, patternF880Aug 24, 2023

  Based on observation, interview and document review, the facility failed to ensure proper hand hygiene and glove use was utilized in the dining area and during cares for 1 of 2 residents (R17) reviewed for dining. In addition, the facility failed to ensure staff labeled and dated tube feeding solution for 1 of 1 residents R44 reviewed for tube feeding. Findings include: R17's minimum data set (MDS) assessment dated [DATE] indicated R17 was cognitively intact. R17's diagnoses included: anemia, major depression, type 2 diabetes, neuropathy, osteoarthritis, restless legs, overactive bladder, presences, COPD, chronic pain, interocular lenses, and coronary artery disease. […]

• No harm, potential for more than minimal, isolatedF688Jul 12, 2024

  Based on observation, interview, and record review, the facility failed to resume restorative services for 1 of 2 residents (R4) reviewed for limited range of motion . Findings include: R4's significant change Minimum Data Set (MDS) assessment, dated 6/15/24 indicated R4 as cognitively intact with no behaviors or rejection of cares, limited upper and lower range of motion to one side, and dependent on staff for activities of daily living (ADLs) R4's diagnoses list included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (limited to no movement following stroke), chronic pain, central pain syndrome (pain as the result in brain injury), muscle weakness, repeated falls, and neurologic neglect syndrome (a disorder that causes the body to favor one… […]

• No harm, potential for more than minimal, isolatedF758Jul 12, 2024

  Based on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures during the use of an antipsychotic medication for 3 of 4 residents (R6, R28, and R56) reviewed for psychotropic medications. Findings include: R6's quarterly Minimum Data Set (MDS) assessment, dated 5/10/24, identified R6 as cognitively intact, required extensive assistance with all activities of daily living (ADL's), and received antipsychotic, antianxiety, and antidepressant medications. […]

• No harm, potential for more than minimal, isolatedF791Jul 12, 2024

  Based on interview and document review, the facility failed to arrange dental services after a non-urgent/routine dental referral was placed for 1 of 1 residents (R36) reviewed for dental concerns. Findings include: R36's quarterly Minimum Data Set (MDS) assessment, dated [DATE], identified moderately impaired cognition with medical diagnoses of diabetes mellitus (DM), hyperlipidemia, seizure disorder or epilepsy, depression, and medically complex conditions. R36 required extensive assistance for most activities of daily living (ADL's) and R36 was usually understood. R36 was identified as having a life expectancy of greater than six months. R36's care plan, edited [DATE], identified R36 wears upper and lower dentures and needs help to cleanse them. […]