Souris Valley Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 20, 2025

  Based on observation, record review, review of facility policy, review of the facility reported incident (FRI) and investigation, and staff interviews, the staff failed to provide appropriate supervision and use of assistive devices for 2 of 2 sampled residents (Resident #1 and #2) who required staff assistance while bathing. Failure to utilize the bath chair safety strap during bathing resulted in a fall with a fracture for Resident #1 and placed all residents at risk of accidents, falls, and/or injuries. During the on-site FRI investigation, the survey team determined noncompliance with regulatory requirements existed on 11/11/25 when facility staff failed to utilize the bath chair safety strap resulting in a fall/fracture.*On 11/18/25 at 2:03 p.m. […]

• Immediate jeopardy, isolatedF880Apr 24, 2025

  Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #18) with Multi-Resistant Staph Aureus (MRSA) (a type of contagious infection resistant to antibiotics) in a wound. Failure to follow infection control practices related to location of a dressing change and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. During the on-site recertification survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/21/25 at 3:55 p.m. The IJ was identified when a staff nurse performed a dressing change in the medication room and failed to wear Personal Protective Equipment (PPE) (a gown). […]

• Immediate jeopardy, isolatedF689Apr 17, 2024

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 5 sampled residents (Resident #35) who required staff assistance and a gait belt with transfers. Failure to provide adequate assistance and/or use the assistive devices appropriately during transfers placed the residents at risk for accidents, falls, and/or injuries. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/16/24 at 5:15 p.m. […]

• Actual harm, isolatedF760Aug 27, 2024

  Based on record review, review of the facility reported incident investigation, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 closed record (Resident #1) receiving insulin. Failure to administer insulin according to a physician's order may have contributed to Resident #1's hospitalization . This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 08/16/24. The facility implemented corrective action on 08/19/24 and completed staff education and began audits on 08/19/24. The final facility reported incident, dated 08/19/24 stated, . […]

• Actual harm, isolatedF697Apr 17, 2024

  Based on record review, policy review, and resident and staff interviews, the facility failed to provide care and services to control pain for 1 of 1 sampled resident (Resident #31) reviewed for pain management. Failure to administer as needed (prn) pain medications and inform the physician of increased use of prn pain medication resulted in Resident #31 experiencing anxiety and mental anguish and may have contributed to the resident experiencing increased and/or unresolved pain. Findings include: Review of the facility policy titled Pain Management occurred on 04/17/24. This policy, dated February 2024, stated, . PURPOSE To provide residents assistance in pain management. To promote well-being by ensuring that residents are as comfortable as possible. […]