Pelican Valley Health Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jan 8, 2025

  Based on observation, interview, and document review, the facility failed to maintain the ice machines located in the kitchen and on the 300 wing in a sanitary manner to prevent potential illness. This deficient practice had the potential to affect all 32 residents who received water from the ice machines. Findings include: During an observation on 1/6/25 at 10:13 a.m., the ice machine in the dining room had a thick white hard powder substance approximately one-fourth of an inch in height around the entire inside and outside of the ice spout. During an observation on 1/6/25 at 11:33 a.m., the ice machine on the 300 wing had a thick white hard powder substance approximately one-fourth of an inch in height around the entire inside and outside of the ice spout. […]

• No harm, potential for more than minimal, widespreadF880Nov 8, 2023

  Based on interview and document review, the facility failed to develop and implement a comprehensive infection control program to include ongoing process and outcome surveillance, and routine analysis of the collected data to ensure infections were not spreading within the facility to other residents and/or employees. This deficient practice had potential to affect all 29 residents in the facility. Findings include: During review of the facility's infection prevention program on 11/6/23 at 3:00 p.m., with the Infection Preventionist (IP), IP stated he received information on resident illnesses when the nurses on the floor completed a resident infection form. […]

• No harm, potential for more than minimal, widespreadF881Nov 8, 2023

  Based on interview and document review, the facility failed to develop an antibiotic stewardship program which included the development of protocols and a system to monitor antibiotic use for 3 of 3 residents (R2, R135, R28) reviewed for antibiotic stewardship. This deficient practice had the potential to affect all 29 residents who resided in the facility. Findings include: On 11/6/23 at 7:30 p.m., the facility's infection control program was reviewed with the director of nursing (DON). The infection control program lacked protocols for a facility-wide system to monitor the use of antibiotics which included appropriate prescribing of antibiotics, and periodic review of antibiotic use by physicians. […]

• No harm, potential for more than minimal, patternF880Jan 8, 2025

  Based on observation, interview and document review, the facility failed to maintain sanitary conditions for mechanical lifts for four (R2, R25, R7, R15) out of five residents observed who used a mechanical lift. Finding include: During an observation on 1/6/25 at 6:59 p.m., nursing assistant (NA)-A assisted R7 into bed with a mechanical lift. NA-A placed the mechanical lift away in the nook without sanitizing the mechanical lift. No sanitizing wipes were in the nook where the lifts were stored. During an observation on 1/7/25 at 8:48 a.m., NA-B took the mechanical lift out of R2's room and placed the mechanical lift in the nook without sanitizing the machine. […]

• No harm, potential for more than minimal, isolatedF880Mar 25, 2026

  Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented in accordance with Centers for Disease Control (CDC) guidelines for 1 of 3 (R8) residents who were reviewed for enhanced barrier precautions.CDC guidelines dated 8/12/22, identified EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. […]