Inspection Reports for
Valley Skilled Nursing

The complaint involved Resident 1 reporting missing personal items on 05/23/2025. The facility did not complete a theft and loss monitoring form at the time, delayed investigation beyond the ten-day policy, and failed to replace or reimburse the items before the resident's discharge.

The facility failed to follow policy to investigate and offer replacement or reimbursement for a resident's missing personal items, specifically a pair of shoes and a hinged knee brace. The investigation and resolution process was delayed beyond the facility's ten-day policy, and no theft and loss form was initially completed.

The facility failed to protect and secure resident PHI and staff private information stored in filing cabinets inside two wooden sheds that were broken into and left unsecured from 2025-04-29 until 2025-05-06. The filing cabinets contained sensitive information including resident medical records and employee files and were not locked. The facility relocated the filing cabinets to a locked metal shed on 2025-05-06. Several facility staff were unaware that PHI and private information were stored in the sheds.

The complaint investigation focused on a medication error where Registered Nurse 2 administered lorazepam to Resident 1 earlier than ordered. The error was reported to the physician, but documentation was incomplete and an incident report was not filed. The investigation included interviews with nursing staff and review of medical records.

The facility failed to ensure medications were administered according to physician orders, resulting in Resident 1 receiving lorazepam earlier than prescribed. Additionally, the medication administration was not properly documented in the Medication Administration Record (MAR) or incident reports, potentially affecting care delivery and causing risk of medication errors.

The complaint investigation found that the facility failed to report an injury of unknown origin for Resident 1 within the required 2-hour timeframe to the California Department of Public Health and the ombudsman, resulting in delayed investigation and risk to the resident. The complaint was substantiated based on interviews and record reviews.

The facility failed to report an injury of unknown origin for Resident 1 in a timely manner, resulting in delayed investigation and potential risk of physical harm. Additionally, the facility failed to develop and implement a comprehensive, person-centered care plan for Resident 1's newly developed lumps and bruising, with insufficient individualized objectives, timeframes, goals, and interventions.

The visit was complaint-related, investigating allegations of abuse, inadequate care, infection control breaches, and failure to follow physician orders.

The facility was found deficient in multiple areas including failure to protect residents from abuse, inaccurate PASARR screening, inadequate assistance with activities of daily living, improper catheter care, failure to administer oxygen per physician orders, failure to accommodate resident food allergies and preferences, and failure to implement infection prevention and control practices including enhanced barrier precautions and proper medication handling.

The facility was found deficient in protecting residents from abuse, ensuring accurate PASARR screening, providing adequate assistance with activities of daily living, catheter care, oxygen administration, dietary accommodations for allergies and preferences, and infection prevention and control practices including enhanced barrier precautions and medication handling.

The complaint investigation focused on Resident 1's administration of Divalproex sodium without a proper diagnosis of seizure disorder. Interviews with nursing staff and review of medical records confirmed the medication was given unnecessarily, leading to concerns from the resident's responsible party and potential side effects.

The facility failed to follow its policies and procedures on psychotropic medication use by administering Divalproex sodium to Resident 1 without a valid diagnosis of seizure disorder. This increased the resident's risk of serious side effects including nausea, vomiting, headaches, liver complications, tardive dyskinesia, and changes in mood and behavior.

The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a fracture and did not complete required change of condition assessments for two residents, resulting in incomplete documentation and potential risk to resident care.

The facility failed to ensure Licensed Vocational Nurses followed hypoglycemia management protocols for one resident, resulting in potential harm. Additionally, the facility did not use disinfectant wipes effective against Clostridium difficile, risking infection transmission.

The complaint investigation found substantiated failures in hypoglycemia management and infection control practices, with potential harm to residents.

The facility failed to ensure Licensed Vocational Nurses followed proper hypoglycemia management protocols for a resident with low blood glucose, including failure to notify the physician and recheck blood glucose timely. Additionally, the facility failed to maintain an effective infection prevention program by using disinfectant wipes that did not kill Clostridium difficile bacteria, increasing the risk of infection transmission.

The facility failed to provide timely written notification of resident transfers to hospital, failed to individualize psychotropic medication care plans, failed to assess blood pressure prior to medication administration, failed to document indications for psychotropic medication, failed to follow fluid restriction orders, failed to provide medications timely upon admission, failed to label medications properly, failed to prepare food in appropriate textures, failed to maintain sanitary kitchen conditions, failed to properly dispose of garbage, and failed to provide minimum room space per resident in multiple rooms.

The facility was found deficient in multiple areas including environmental safety hazards, care planning, medication administration, infection control, dietary services, staffing, and documentation. Specific issues included unsafe window sills, incomplete care plans, medication errors, inadequate infection control practices, dietary service deficiencies, and incomplete medical record documentation.