Mill Valley Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Apr 15, 2021

  Based on clinical record review, staff interview, physician interview, Power of Attorney (POA) interview, professional drug reference, emergency services record review, and social media postings, the facility failed to provide comprehensive cardiac assessments for a resident with a recent history of heart surgery; failed to transcribe and clarify cardiac medication orders; and failed to notify the cardiologist of acute cardiac change of condition for 1 of 12 residents reviewed for assessment and intervention (Resident #3). Resident #3 complained of indigestion over a span of several days, reached out to 911 on [DATE], and on [DATE] the resident found unresponsive and CPR (cardiopulmonary resuscitation) started. […]

• No harm, potential for more than minimal, patternF656Jan 19, 2022

  Based on observation, record review, and staff interviews the facility failed to follow the Care Plan for one of four residents (Resident#4), and failed implement a Care Plan for 3 of 3 residents (Resident #14,#21, and #22). The facility reported a census of 27 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident#4 required total assistance of two staff members for transfers, and bathing and the resident required extensive assistance of one staff for personal hygiene. The MDS documented the resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan documented the resident experienced occasional incontinence related to impaired mobility and diuretic medication. […]

• No harm, potential for more than minimal, isolatedF689Jul 25, 2024

  Based on observation, record review, staff interview, and policy review the facility failed to follow appropriate transfer techniques resulting in injury for 1 of 1 resident reviewed (Resident #184). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) report dated 9/21/23 for Resident #184 documented a Brief Interview for Mental Status score of 6/15 indicating severe cognitive impairment. The MDS further indicated diagnoses including: non-traumatic brain dysfunction, non-Alzheimer's dementia, and arthritis. The Therapy Progress Note dated 10/8/23 reported Resident #184 attempted two stand pivot transfers with two assist but was unable to do it adequately, causing termination of transfer to prevent rolling an ankle. […]

• No harm, potential for more than minimal, isolatedF684Feb 8, 2024

  Based on clinical record review, staff interview, and facility policy review, the facility failed to document Weekly Pressure Ulcer Assessments for 2 of 3 residents reviewed with pressure ulcers (Residents #2 and #3). The pressure ulcers for these 2 residents worsened during the missed assessment. The facility reported a census of 34. The Minimum Data Set (MDS) Assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• No harm, potential for more than minimal, isolatedF550May 18, 2023

  Based on observation, record review, resident and staff interviews, the facility failed to maintain dignity for two of fourteen residents reviewed (Residents #8 and #12). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #12 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and had the following diagnoses: Anemia, Hyponatremia and Malnutrition. The MDS identified the resident required extensive staff assistance with most activities of daily living and totally dependent on staff for locomotion on and off the unit and documented the resident as continent of bladder and bowel. […]