Spring Valley Health and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 25, 2024

  Based on interviews and record reviews, the facility failed to protect a resident's right to be free from sexual abuse. The facility did not implement interventions to protect residents (R) from sexual abuse by a resident. Not implementing interventions affected 1 of 2 residents (R1) reviewed for sexual abuse. *On 03/28/24, a Certified Nursing Assistant (CNA) found R2 in R1's room. R2 was shirtless and zipping and buttoning R2's pants while in R1's bed. R1, who is cognitively impaired, stood in the middle of the room with a T-shirt and no pants. The facility did not implement appropriate interventions to prevent a second occurrence of sexual abuse from occurring. *On 04/01/24, a CNA found R2 in R1's room. R1 was in bed on R1's back. R2 was lying with R2's head next to R1's feet. […]

• Immediate jeopardy, isolatedF580Jun 21, 2022

  Based on record review and interview, the facility did not immediately consult with the physician for 1 of 2 residents reviewed for a significant change in condition (R1). The facility did not immediately consult with R1's physician after R1 sustained a fall causing a change in condition to his right foot. This fall resulted in the resident's foot hanging on by one (or possibly two) tendon(s). There is no evidence that staff, who were expecting the foot to fall off at any time, consulted with the physician about this or sought medical direction for continued care. The facility did not consult with the physician after the tendon was cut to inform the physician what had been done. […]

• Immediate jeopardy, isolatedF684Jun 21, 2022

  Based on interview and record review, the facility did not provide care consistent with professional standards of practice and with the resident's wishes for care and treatment for 1 of 2 Residents reviewed (R1) who experienced a significant change in condition. R1 was admitted with frostbitten feet that were in need of treatment. R1 did not have weekly assessments to include measurements and the condition of the affected feet. When R1 fell on [DATE], R1's foot became mostly detached. Nursing did not consult with the physician about this change. On 05/27/22, a Registered Nurse (RN) worked outside her scope of practice and cut the remaining tendons to amputate the foot. […]

• Immediate jeopardy, isolatedF849Jun 21, 2022

  Based on interview and record review, the facility failed to ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 2 hospice residents (R1). R1's plan of care was not coordinated and communicated adequately between the facility and hospice regarding R1's ongoing foot condition or when R1's foot was removed by an RN. The facility did not develop a communication plan that included how communication would be provided and documented between the facility and hospice to ensure the needs of the resident were addressed and met. […]

• Actual harm, isolatedF689Aug 1, 2024

  Based on observation, interview, and record review, the facility did not ensure the residents' environment remains as free of accident hazards as possible. Two of four residents (R) reviewed for falls with history of falls (R26 and R31) did not have post fall assessments, care plan interventions updated after falls, and had subsequent falls with major injuries. R26 and R31 are being cited at actual harm. R6 and R2 did not have post fall assessments and care plan updates after falls. One resident (R14) did not have a safety assessment or care plan for leaving facility campus and traveling on a busy highway with power wheelchair. […]