Pearl Valley Rehabilitation And Nursing At Gowrie,
Inspection Findings
F-Tag F758
F-F758 (regulation for use of psychotropic medication) audit sheets with
the Director of Nursing (DON) and the Administrator (ADM) listed audit dates of 2/7/25 and 2/14/25. The documentation listed the DON marked yes, they re educated licensed nursing staff and Certified Medication Aides of the expectation of documenting nonpharmacological interventions prior to administering psychotropic medications and the DON would audit psychotropic PRN (as needed) medication administration
record to ensure nonpharmacological intervention weekly X 4 weeks. The form included a resident's name with the DON's initials documented. When asked if they found any noncompliance when completing the audit, the DON responded she would have corrected and fixed at that time if so. When inquired if the DON had any documentation if she provided more education or the audit was not in compliance, the ADM replied
it would be documented on the sheet below the audit checks and the form didn't have documentation of a concern with the audit being in compliance. The DON confirmed the audits were in compliance.
Interview on 2/24/25 at 2:30 PM, the ADM confirmed the audits on 2/7/25 and 2/14/25 shouldn't be in compliance as Resident #2 received a PRN psychotropic medication without documentation of behaviors and nonpharmacological interventions.
The survey identified the following concerns during the current survey that the prior survey team cited during
the surveys in the past.:
a. QAPI program and plan.
b. Free of accidents, hazards, and supervision.
c. Free from unnecessary psychotropic Medications/ PRN (as needed) Use.
d. Notification of Changes(Injury/Decline/ Room, etc.)
The facility's policy, QAPI Plan and Program effective August 2024, directed the facility shall develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focused on indicators of the outcomes of care and quality of life.
Interview on 2/24/25 at 3:00 PM, the ADM acknowledged the concerns with repeated deficiencies and concerns with QAPI. The ADM felt like the facility worked very hard and just couldn't get a break. The ADM further stated the facility still used some agency nurses but no longer Certified Nurse Aides, and hopes that will help.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 165344