Valley View Rehab And Nursing Center

F-F684

28 Pa Code 201.20(a)(6)(d) Staff development

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 395895 Department of Health & Human Services Printed: 08/26/2025 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 395895 B. Wing 05/23/2025

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

Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36798 potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to develop and Residents Affected - Few implement an individualized person-centered care plan to address dementia and cognitive loss displayed by two of four residents reviewed (Residents 86 and 89).

Findings include:

Clinical record review for Resident 86 revealed that the facility admitted her on November 25, 2024, with diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 86's significant change minimum data set (MDS, a form completed at specific intervals to determine care needs) assessment dated [DATE REDACTED], indicated that the facility assessed Resident 86 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 86's care plan entitled, Impaired cognitive function/dementia or impaired thought processes r/t (related to) Vascular Dementia initiated on December 3, 2024, failed to identify individualized person-centered interventions to address Resident 86's dementia and cognitive loss.

Clinical record review for Resident 89 revealed that the facility admitted her on November 10, 2022, with a diagnosis of Dementia added on January 12, 2023. A review of Resident 89's annual MDS assessment dated [DATE REDACTED], indicated that the facility assessed Resident 89 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 89's care plan entitled, Impaired cognitive function/impaired thought processes, moderately impaired per BIMS (brief interview for mental status, determines level of cognition); dementia with psychosis, dated August 7, 2023, failed to identify individualized person-centered interventions to address Resident 89's dementia and cognitive loss.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 22, 2025, at 2:55 PM.

28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 395895 Department of Health & Human Services Printed: 08/26/2025 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 395895 B. Wing 05/23/2025

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

Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or 20725 potential for actual harm Based on a review of select facility policies and procedures, clinical record review, and family and staff Residents Affected - Few interview, it was determined that the facility failed to obtain routine dental services for one of three residents reviewed for dental concerns (Resident 67).

Findings include:

The facility policy entitled, Dental Exams, last reviewed November 21, 2024, revealed that each resident will receive, at a minimum, an annual oral examination with a dentist or his/her choice. In addition to the minimum oral examination, each resident will be offered dental services every six months as his/her insurance will allow. Any resident or resident's responsible party may elect to have the annual oral examination done with the contract dentist.

Interview with Resident 67's daughter on May 20, 2025, at 10:10 AM revealed that Resident 67 has natural teeth; however, Resident 67's daughter did not know the last time Resident 67 received professional dental services. Resident 67's daughter stated that she, .would love to see that happen.

Clinical record review for Resident 67 revealed that the facility admitted her on May 3, 2023, with Medicare as her primary payer source. Resident 67 began to pay privately for her care on June 1, 2023. Resident 67's primary payer source converted to Medicaid on May 1, 2024.

A Dental Services form (document the facility utilized to obtain consent for contracted dental services) signed by Resident 67's daughter on May 3, 2023, (while Resident 67 did not receive Medicaid payment for services) indicated that Resident 67's daughter declined dental care.

Annual MDS assessments (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 2, 2024, and May 3, 2025, assessed Resident 67 with obvious or likely cavities or broken natural teeth. The Care Area Assessment for Dental Care indicated that the facility would proceed to a care plan in May 2024; however, the facility decided to not proceed to a care plan in May 2025.

Review of Resident 67's plans of care revealed no evidence that the facility developed a care plan to address the likelihood that Resident 67 had decayed or broken teeth or attempted an intervention for professional dental services following either the May 2, 2024, or May 3, 2025, MDS assessments.

Care Conference Meeting documentation dated November 6, 2024, at 10:00 AM indicated that Resident 67's daughter attended the meeting.

Care Conference Meeting documentation dated January 15, 2025, at 10:43 AM indicated that Resident 67's daughter attended via telephone.

Care Conference Meeting documentation dated May 14, 2025, at 12:57 PM indicated that staff emailed updates to Resident 67's daughter because she was unable to attend.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 395895 Department of Health & Human Services Printed: 08/26/2025 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 395895 B. Wing 05/23/2025

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

Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

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 0791 Resident 67's clinical record contained no evidence that the facility afforded Resident 67's daughter the opportunity to accept dental services provided under the Medicaid benefit in the year since her mother's Level of Harm - Minimal harm or payment source changed. potential for actual harm

The surveyor reviewed the above information regarding concerns related to Resident 67's dental needs Residents Affected - Few during an interview with the Nursing Home Administrator and the Director of Nursing on May 21, 2025, at 2:30 PM and the Director of Nursing on May 22, 2025, at 11:20 AM.

Nursing documentation dated May 22, 2025, at 11:32 AM (following the surveyor's questioning) revealed that staff contacted Resident 67's daughter regarding dental services now that Resident 67 is approved for medical assistance (Medicaid). Resident 67's daughter stated that she would be interested in services for her mother from the facility's contracted dental provider and asked that the forms be mailed to her for signature.

28 Pa. Code 211.15 Dental services

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 395895 Department of Health & Human Services Printed: 08/26/2025 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 395895 B. Wing 05/23/2025

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

Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

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 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 18229 potential for actual harm Based on a review of select facility policies and procedures, observation, and staff interview, it was Residents Affected - Few determined that the facility failed to ensure an environment free from the potential spread of infection on one of six residents reviewed for infection control (Resident 83).

Findings include:

The policy entitled Standard Precautions and Transmission-Based Precautions, last reviewed without changes March 18, 2025, revealed the CDC recommends two tiers of precautions. In the first tier are those precautions designed for the care of all residents, regardless of their diagnosis or presumed infection status. Implementation of these standard precautions is the primary strategy for successful infection prevention and control. The second tier of precautions are designed only for the care of specified residents on a case-by-case basis. Airborne, Contact, and Droplet precautions are used for persons known or suspected to be infected or colonized with highly transmissible pathogens. These precautions will be instituted for any resident who has an active infection and/or requires more extensive infection control measures. These precautions are to be used in addition to standard precautions. Contact precautions are used for residents known or suspected to be infected or colonized with microorganisms transmitted by direct contact with a resident or by indirect contact such as touching environmental surfaces. Examples of such illnesses include Vancomycin Resistant Enterococcus (VRE).

Clinical record review revealed the facility admitted Resident 83 on February 21, 2025. A urine culture collected on April 23, 2025, noted with 10,000-50,000 cfu (colony forming unit)/mL (milliliter) of enterococcus faecium VRE.

A physician's progress note dated April 25, 2025, at 10:35 AM indicated Resident 83's urine was positive for enterococcus faecalis and enterococcus faecium VRE. The physician noted they would start Macrobid 100 milligrams (mg) twice a day for five days but may need to change depending on pending sensitivities.

Further review of Resident 83's clinical record revealed an order for contact precautions for VRE in her urine

on April 27, 2025.

Interview with Employee 1 (infection preventionist) on May 23, 2025, at 9:40 AM confirmed there was a delay

in starting Resident 83's transmission-based precautions. Employee 1 stated the nurse supervisor did not implement contact precautions over the weekend.

The surveyor reviewed the concerns related to transmission-based precautions during an interview with the Director of Nursing on May 23, 2025, at 10:31 AM.

483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control

Previously cited deficiency 6/20/24

28 Pa. Code 211.10(a)(c) Resident care policies

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 395895 Department of Health & Human Services Printed: 08/26/2025 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 395895 B. Wing 05/23/2025

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

Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

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 28 Pa. Code 211.12(d)(1)(5) Nursing services

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 395895