Owen Valley Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Owen Valley Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 20, 2021

  Based on observation, interview, and record review, the facility failed to ensure a fall intervention was in place for a resident which resulted in a fall and sustained [MEDICAL CONDITION] that required medical intervention for wound closure for 1 of 4 residents reviewed for accidents (Resident C) Findings include: On 1/19/21 at 11:50 a.m., Resident C was observed to be sitting in his wheelchair in his room. Resident C's bed was observed to have bilateral mobility bars at the head of his bed. On 1/19/21 at 2:32 p.m., Resident C's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident First Meeting Minutes, dated 10/22/20 at 2:45 p.m., indicated bed rails were still appropriate and least restrictive. […]

• No harm, potential for more than minimal, widespreadF851Feb 2, 2024

  Based on interview and record review, the facility failed to electronically submit to the Centers for Medicare and Medicaid (CMS) complete and accurate Registered Nurse (RN) hours based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for quarter 4 of fiscal year 2023 (7/1/23-9/30/23). Findings include: On 2/2/24 at 2:01 p.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN hours for 7/8/23, 7/9/23, 7/16/23, 9/23/23, 9/24/23, and 9/30/23. On 2/2/24 at 2:03 p.m., the staffing sheets and time cards for the above dates were reviewed and indicated the facility did have RN hours for those dates. […]

• No harm, potential for more than minimal, patternF636Dec 9, 2024

  Based on interview and record review, the facility failed to ensure the admission Minimum Data Set (MDS) assessment was completed within 14 calendar days from the admitted for 4 of 4 residents reviewed for Resident Assessment. (Resident 132, Resident 133, Resident 282, Resident 75) Findings include: 1. On 12/9/24 at 11:56 a.m., Resident 132's clinical record was reviewed. The diagnosis included, but was not limited to, urinary tract infection. The resident was admitted to the facility on [DATE]. The admission MDS assessment for Resident 132 indicated it was still in progress. The completion date should have been on 12/2/24, which was 14 calendar days from the admitted . 2. On 12/9/24 at 12:00 p.m., Resident 133's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF921Feb 2, 2024

  Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment for 3 of 4 units observed. A urine odor was observed and air vents were not clean. (200 unit, 300 unit, 400 unit) Findings include: 1. On the following dates and times, the full length of the 200 unit hallway was observed to have a strong odor of urine: - On 1/29/24 at 11:20 a.m. and 2:40 p.m. - On 1/30/24 at 10:40 a.m., 12:05 p.m., and 3:00 p.m. - On 2/2/24 at 9:45 a.m., 11:10 a.m., and 1:25 p.m. 2. […]

• No harm, potential for more than minimal, patternF677Mar 9, 2023

  Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for 4 of 6 residents reviewed for activities of daily living. (Resident 39, Resident 178, Resident 24, Resident 56) Findings include: 1. On 3/6/23 at 10:50 a.m., Resident 39 was observed in bed in her room with whiskers approximately 1/2 inch long on her chin. On 3/8/23 at 2:40 p.m., Resident 39 was observed in bed in her room with whiskers approximately 1/2 inch long on her chin. On 3/9/23 at 10:30 a.m., Resident 39 was observed in the activity area with whiskers approximately 1/2 inch long on her chin. During an interview on 3/8/23 at 2:25 p.m., the resident indicated she would rather have not had whiskers on her chin. […]