Valley Manor And Rehabilitation Center

F-F880 Infection Prevention and Control.

- Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 99 265356 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265356 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Manor and Rehabilitation Center 1410 Hospital Drive Excelsior Springs, MO 64024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff Level of Harm - Minimal harm or hands and clothing. potential for actual harm - EBP are indicated for residents with any of the following: Residents Affected - Some Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or

Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with

a MDRO.

- Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

1. Review of Resident #34's Annual MDS (Minimum Data Set), A mandated assessment completed by facility staff on 6/10/24., showed:

- Severely Impaired Cognition with advanced dementia;

- History of Stroke ( paralysis to one or both sides of the body);

- Inability to speak, swallow, or make needs known;

- Gastric tube for enteral feeding (A tube inserted into the stomach for liquid nutrition to be administered through);

- Total assist of 2 people for all activities of daily living (ADL);

- Staff to anticipate and meet all needs of the resident.

Review of undated care plan showed:

- Resident required total care.

- Frequently Incontinet of bowel and bladder.

- Requires a gastric feeding tube for nutrition.

- No care plan regarding risk for MDRO infections.

- No care plan to address minimize risk for infections with staff interventions for use of PPE (Personal Protective Equipment-such as gloves, gowns).

Observation of the resident from 7/7/24 through 7/10/24., showed:

- No identification of enhanced precautions for the resident was placed outside the resident's room or on the door.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of 99 265356 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265356 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Manor and Rehabilitation Center 1410 Hospital Drive Excelsior Springs, MO 64024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - No resources to alert staff on what type of PPE should be used when providing personal cares for the resident. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #63's Admission MDS, completed on 5/31/4., showed:

Residents Affected - Some - Total care of all ADLS

- Behaviors of refusing care.

- Not cognitively intact

- History of repeated UTI

- Chronic Urinary Retention with a Urinary Catheter.

-Diagnoses: Depression, Anxiety, Repeated Falls, Muscle weakness and wasting.

Review of undated care plan showed:

- Resident required total care.

- Frequently Incontinet of bowel .

- Requires a urinary catheter for emptying of bladder and staff to manage.

- No care plan regarding risk for MDRO infections.

- No care plan to address minimize risk for infections with staff interventions for use of PPE (Personal Protective Equipment-such as gloves, gowns) when provide personal care or management of urinary catheter.

Observation of the resident from 7/7/24 through 7/10/24., showed:

- No identification of enhanced precautions for the resident was placed outside the resident's room or on the door.

- No resources to alert staff on what type of PPE should be used when providing personal cares for the resident.

3. Review of Resident #23's Five Day Medicare MDS, completed on 5/17/24., showed:

-The resident was readmitted from hospital with infected hardware from hip repair;

-History of Multi Drug Resistant Organisms;

-Impaired Cognition;

-Assistance with all Activities of daily living (ADL);

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of 99 265356 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265356 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Manor and Rehabilitation Center 1410 Hospital Drive Excelsior Springs, MO 64024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -Diagnoses: Anxiety, Delusional Disorders (altered reality), Fracture of left femur bone, Significantly impaired mobility upper and lower extremities, as well as back and spinal disorders, and Depression. Level of Harm - Minimal harm or potential for actual harm Review of undated care plan showed:

Residents Affected - Some - Resident required total care.

- Frequently Incontinet of bowel and bladder.

- No care plan regarding risk for and history of MDRO infections.

- No care plan to address minimize risk for infections with staff interventions for use of PPE (Personal Protective Equipment-such as gloves, gowns) when provide personal cares.

Observation of the resident from 7/7/24 through 7/10/24., showed:

- No identification of enhanced precautions for the resident was placed outside the resident's room or on the door.

- No resources to alert staff on what type of PPE should be used when providing personal cares for the resident.

During an interview on 7/7/24 at 11:30 A.M,. NA A said:

-He/She did not know if resident #23 should be on enhanced isolation precuations.

- He/She was not sure if resident had a history of infections.

- He/She was not sure what type of PPE should be used when caring for the resident.

During an interview on 7/7/24 at 3:20 P.M., CNA C., said:

- He/She was not sure what enhanced barrier precautions was.

- Was not sure if resident #34, #63 should be on isolation.

- Was aware that resident #34 was provided nutrition through a tube in the stomach.

- Was aware that resident #63 has a urinary cath.

During an interview on 7/8/24 at 9:11 A.M., CNA D., said:

- He/She did not belive that resident #34 or #63 should be on isolation, and was not told that in report.

- Did not know if an isolation should be worn with peri care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of 99 265356 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265356 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Manor and Rehabilitation Center 1410 Hospital Drive Excelsior Springs, MO 64024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 7/10/24 at 11:30 A.M., NA C., said she did not know what equipment would be needed for enhanced precuations or if the resident should be on isolation at all. Level of Harm - Minimal harm or potential for actual harm 31102

Residents Affected - Some 4. Review of the facility's policy for hand washing/hand hygiene, revised October 23, showed, in part:

- The facility considered hand hygiene the primary means to prevent the spread of healthcare -associated infections;

- Hand hygiene is indicated: immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids or contaminated surfaces, after touching a resident, after touching the residetn's environment, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal.

Review of Resident #58's Admission MDS, dated [DATE REDACTED] showed:

- Cognitive skills intact;

- Required assistance with set up and clean up with eating and oral hygiene;

- Dependent on staff assistance for toilet use and transfers;

- Supervision or touch assistance with personal hygiene;

- Had a catheter (sterile tube inserted into the bladder to drain urine);

- Occasionally incontinent of bowel;

- Diagnoses included diabetes mellitus, high blood pressure, anxiety, atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells).

Review of the resident's care plan, dated 6/12/24 showed:

- The resident had a urinary catheter. Catheter care every shift.

Observation on 7/9/24 at 5:36 A.M., showed:

- CNA D entered the resident's room, did not wash his/her hands and applied gloves;

- CNA D obtained supplies and arranged them on the resident's over the bed table;

- CNA D removed gloves, washed his/her hands and applied new gloves;

- CNA D unfastened the resident's incontinent brief and turned the resident on his/her side;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of 99 265356 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265356 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Manor and Rehabilitation Center 1410 Hospital Drive Excelsior Springs, MO 64024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - CNA D cleaned fecal material from the resident's buttocks, removed gloves, did not wash his/her hands and applied new gloves; Level of Harm - Minimal harm or potential for actual harm - CNA D continued to clean fecal material from the resident's rectal area;

Residents Affected - Some - CNA D removed gloves, did not wash his/her hands and applied new gloves;

- CNA D placed a clean incontinent brief under the resident then turned the resident on his/her side and provided perineal care to the front skin folds. CNA D removed gloves and washed his/her hands and put items away.

During an interview on 7/10/24 at 6:35 A.M., CNA D said:

- He/she should wash his/her hands when entering the resident's room, between glove changes, after cleaning fecal material and before leaving the resident's room.

During an interview on 7/10/24 at 9:15 A.M. the Director of Nursing and the Assistant Director of Nursing together both said they were unsure which resident's should currently be on enhanced precuations, and what

the current criteria and recommendations were.

During an interview on 7/10/24 at 12:10 P.M., the Administrator said she would expect all residents who met

the criteria for enhanced precuations, be placed on enhanced precuations

During an interview on 7/10/24 at 12:50 P.M., the DON said;- Staff should wash their hands anytime walk in

the he resident's room, between glove changes, when cleaning fecal material and before leaving the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of 99 265356 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265356 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Manor and Rehabilitation Center 1410 Hospital Drive Excelsior Springs, MO 64024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 46987 potential for actual harm Based on interview and record review, the facility failed to establish an infection prevention and control Residents Affected - Some program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 68.

The revised facility Antibiotic Stewardship policy,dated December 2016 showed in part: The purpose of antibiotic stewardship is to monitor the use of antibiotics in our residents and to include training, orientation, and education of staff with emphasize on the importance of antibiotics stewardship, and inappropriate use of antibiotics. Antibiotics usage and outcome will be collected and documented using a facility-approved antibiotics surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship.

1. The facility did not provide Antibiotic Stewardship Program documentation that should include ongoing monthly survelliance and monitoring of the following:

- Protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic;

- Procedures to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use;

- Procedures to promote and implement a facility-wide system to monitor the use of antibiotics including a system of reports related to monitoring antibiotic usage and resistance data;

- Designated appropriate facility staff accountable for promoting and overseeing antibiotic stewardship;

- Accessing pharmacists and others with experience or training in antibiotic stewardship;

- Implementation of a policy or practice to improve antibiotic use;

- Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff;

- Educate staff and residents about antibiotic stewardship.

During an interview 07/09/24 04:21 PM, the Director of Nursing said:

- She is now in charge of Antibiotic Stewardship and infection prevention.

- The antibiotic tracking book I have doesnt have much information in it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of 99 265356 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265356 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Manor and Rehabilitation Center 1410 Hospital Drive Excelsior Springs, MO 64024

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 - She started in May, and was not aware of who had been in charge of Infection Prevention prior to her start date. Level of Harm - Minimal harm or potential for actual harm - Was unsure at the time of the interview who was on antibiotics or where data to show trends and antibiotic activity had been monitored and tracked in previous months. Residents Affected - Some

During an interview on 7/10/24 at 12:20 P.M. the Administrator said:

- Antibiotic Stewardship is important and should be followed and monitored.

- The Director of Nursing is new to her position and is now also managing infection control and antibiotic stewardship.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of 99 265356