Deficiencies (last 4 years)
Deficiencies (over 4 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
458% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a resident's right to retain and use personal possessions after items were reported missing.
Complaint Details
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.
Findings
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.
Deficiencies (1)
F 0557: The facility failed to ensure one resident's right to retain and use personal possessions when missing items were not investigated or replaced timely. The resident's pair of shoes and hinged knee brace were lost without replacement or reimbursement.
Report Facts
Estimated value of missing items: 100
Date missing items reported: May 23, 2025
Date survey completed: Jun 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Responsible for investigating missing resident belongings and completing theft and loss monitoring forms |
| Assistant Director of Nursing | Assistant Director of Nursing | Reviewed missing items investigation and progress notes |
| Director of Nursing | Director of Nursing | Oversaw missing items investigation process and policy adherence |
| Registered Nurse | Registered Nurse | Reviewed resident's inventory of personal effects and admission records |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure a resident's right to retain and use personal possessions after Resident 1 reported missing personal items on 5/23/25.
Complaint Details
Complaint investigation regarding missing personal belongings of Resident 1, substantiation indicated by failure to follow facility policy and timely investigation.
Findings
The facility failed to follow policy to investigate and offer replacement or reimbursement for Resident 1's missing pair of shoes and hinged knee brace. The Social Services Director and Assistant Director of Nursing confirmed no theft and loss monitoring form was completed timely, and the missing items were not replaced or reimbursed as required.
Deficiencies (1)
Failure to ensure Resident 1's right to retain and use personal possessions when missing items were not investigated or replaced/reimbursed.
Report Facts
Estimated value of missing items: 100
Date item went missing: May 23, 2025
Timeframe for resolving missing items: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Responsible for investigating missing resident belongings and completing Theft and Loss Monitoring forms |
| Assistant Director of Nursing | Assistant Director of Nursing | Reviewed missing items investigation and confirmed facility procedures |
| Director of Nursing | Director of Nursing | Oversaw missing items investigation process and facility policy adherence |
| Registered Nurse | Registered Nurse | Reviewed Resident 1's Inventory of Personal Effects and admission documentation |
Inspection Report
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was conducted to investigate the facility's failure to protect and secure resident protected health information (PHI) and staff private information after two storage sheds were broken into on 2025-04-29.
Findings
The facility failed to secure resident medical records and staff private information stored in unsecured filing cabinets inside two wooden sheds that were broken into. The filing cabinets containing sensitive information were left unlocked and exposed until they were relocated to a locked metal shed on the day of the inspection.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. Two of seven sheds containing filing cabinets with resident PHI and staff private information were broken into and left unsecured from 2025-04-29 until 2025-05-06.
Report Facts
Files: 200
Sheds: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Service Director | Environmental Service Director | Interviewed regarding unsecured sheds and filing cabinets |
| Medical Records Director | Medical Records Director | Interviewed regarding unsecured resident PHI and staff private information |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding awareness of unsecured PHI and staff information |
| Director of Nursing | Director of Nursing | Interviewed regarding the break-in and unsecured PHI |
| Administrator | Administrator | Interviewed regarding facility knowledge and response to unsecured PHI |
Inspection Report
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was conducted due to a break-in at the facility's sheds on 2025-04-29, which resulted in unsecured resident protected health information (PHI) and staff private information being exposed.
Findings
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.
Deficiencies (1)
Failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards due to unsecured storage in broken-into sheds.
Report Facts
Number of sheds broken into: 2
Number of files: 200
Number of sheds: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Service Director | Environmental Service Director | Interviewed regarding the unsecured sheds and storage of PHI |
| Medical Records Director | Medical Records Director | Interviewed regarding the unsecured filing cabinets containing PHI |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about awareness of PHI storage and security |
| Director of Nursing | Director of Nursing | Interviewed about the break-in and security of PHI |
| Administrator | Administrator | Interviewed about facility knowledge and response to the break-in and PHI security |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error involving the incorrect administration of lorazepam to a resident (Resident 1) at Valley Skilled Nursing Center.
Complaint Details
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.
Findings
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.
Deficiencies (2)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of Resident 1 when lorazepam was administered earlier than prescribed, risking respiratory depression and other side effects.
F 0842: The facility failed to maintain complete and accurate medical records for Resident 1, as the lorazepam dose was not documented in the MAR or incident report, risking errors in medical treatment and plan of care.
Report Facts
Medication dose: 0.5
Medication administration time: 16.75
Medication administration time: 11.45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Named in medication error finding for administering lorazepam early and incomplete documentation |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication error and facility procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding medication error, documentation, and monitoring |
| LVN | Licensed Vocational Nurse | Interviewed regarding notification procedures following medication errors |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error involving Resident 1, where lorazepam was administered earlier than prescribed, potentially causing harm.
Complaint Details
The complaint investigation found that Resident 1 was administered lorazepam too early by RN 2, who failed to check the five rights of medication administration and did not document the administration properly. The physician was notified, and Resident 1 was monitored for adverse reactions. Documentation and notification procedures were not fully followed.
Findings
The facility failed to ensure medications were administered according to physician's orders, resulting in Resident 1 receiving lorazepam too early. Additionally, the medication administration was not properly documented in the Medication Administration Record (MAR) or incident reports, which could affect care delivery and cause errors.
Deficiencies (2)
Failed to ensure medications were administered to meet the needs of Resident 1 when lorazepam was given earlier than prescribed.
Failed to maintain complete and accurate medical records for Resident 1, including failure to document lorazepam administration in the MAR and failure to complete an incident report.
Report Facts
Medication dose: 0.5
Medication administration time: 16.45
Medication administration interval: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Administered lorazepam early to Resident 1 and failed to document properly |
| Assistant Director of Nursing | ADON | Interviewed regarding medication error and facility procedures |
| Director of Nursing | DON | Interviewed regarding medication error, documentation failures, and monitoring |
| Licensed Vocational Nurse | LVN | Interviewed regarding notification procedures following medication error |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an injury of unknown origin for Resident 1, and failure to develop and implement a comprehensive person-centered care plan for the resident's newly developed lumps and bruising.
Complaint Details
The complaint investigation focused on the failure to report an injury of unknown origin for Resident 1 and the lack of a comprehensive care plan for the resident's condition. The failure to report was substantiated as the facility did not notify the California Department of Public Health and the ombudsman within the required timeframe.
Findings
The facility failed to report an injury of unknown origin to the California Department of Public Health and the ombudsman within the required 2-hour timeframe, resulting in delayed investigation and risk of harm. Additionally, the facility did not develop a thorough, individualized care plan for Resident 1's right shoulder lump and chest bruising, placing the resident at risk for complications and delayed healing.
Deficiencies (2)
F 0609: The facility failed to timely report an injury of unknown origin for Resident 1 within 2 hours to proper authorities, delaying investigation and placing the resident at risk of harm.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan for Resident 1's right shoulder lump and chest bruising, lacking detailed objectives, timeframes, goals, and interventions.
Report Facts
Lump measurement: 12
Lump measurement: 7
Pain medication dosage: 5.325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Assessed Resident 1's right shoulder lump and reported pain; involved in documentation and communication with provider | |
| Director of Nursing (DON) | Reviewed Resident 1's records and stated reporting failure and care plan deficiencies | |
| Director of Staff Development (DSD) | Interviewed regarding reporting requirements for injuries of unknown origin | |
| Assistant Director of Nursing (ADON) | Reviewed care plans and stated lack of comprehensive person-centered care plan for Resident 1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an injury of unknown origin for Resident 1, which was not reported to the California Department of Public Health and the ombudsman within the required 2-hour timeframe.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to timely report an injury of unknown origin to proper authorities within 2 hours as required by law.
Failure to develop and implement a comprehensive person-centered care plan for Resident 1's right shoulder lump and chest bruising with thorough and individualized objectives, timeframes, goals, and interventions.
Report Facts
Lump measurement: 12
Lump measurement: 7
Pain medication dosage: 5.325
Date of injury documentation: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Assessed Resident 1's right shoulder lump and reported on injury and care |
| Director of Nursing | Director of Nursing | Reviewed Resident 1's records and stated reporting requirements and care plan deficiencies |
| Director of Staff Development | Director of Staff Development | Interviewed regarding reporting procedures for injuries of unknown origin |
| Assistant Director of Nursing | Assistant Director of Nursing | Reviewed and commented on Resident 1's care plans and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 14, 2025
Visit Reason
The inspection was conducted based on complaint investigations and regulatory oversight to assess compliance with resident rights, care standards, infection control, and other regulatory requirements at Valley Skilled Nursing Center.
Complaint Details
The visit was complaint-related, investigating allegations of abuse, inadequate care, infection control breaches, and failure to follow physician orders.
Findings
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.
Deficiencies (7)
Failed to protect Resident #44 from physical abuse by another resident.
Failed to ensure accurate Level I PASARR screening for Resident #35's serious mental illness diagnosis.
Failed to assist Resident #7 with nail care as part of activities of daily living.
Failed to provide indwelling urinary catheter care per policy and maintain catheter bag below bladder level for Resident #111.
Failed to administer oxygen according to physician orders for Residents #6, #24, and #111.
Failed to provide food accommodating allergies and preferences for Residents #257 and #41.
Failed to implement infection prevention and control program including enhanced barrier precautions and proper infection control practices for Residents #111, #24, #46, and others.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Witnessed abuse incident and involved in catheter care and wound care infection control breaches |
| Licensed Vocational Nurse #14 | LVN | Administered medications via gastrostomy tube without gown; unaware of enhanced barrier precautions |
| Certified Nursing Assistant #6 | CNA | Documented oxygen saturation and involved in care of Resident #6 |
| Registered Nurse #9 | RN | Prepared medications with bare hands; failed to follow medication handling protocols |
| Dietary Aide #12 | Dietary Aide | Responsible for plating meals and checking tray cards for allergies and preferences |
| Dietary Manager | Dietary Manager | Printed tray cards and oversaw dietary staff checking allergies and preferences |
| Director of Nursing | DON | Provided multiple interviews regarding expectations for care, infection control, and policy adherence |
| Medical Doctor #5 | MD | Provided medical oversight and expectations for oxygen therapy and infection control |
| Director of Staff Development | DSD | Performed wound care with infection control breaches |
| Certified Nursing Assistant #20 | CNA | Failed to wear PPE during transfer and linen removal for Resident #24 on enhanced barrier precautions |
| Registered Dietician | RD | Discussed allergy list management and dietary preferences |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 14, 2025
Visit Reason
Routine inspection of Valley Skilled Nursing Center to assess compliance with regulatory requirements including resident care, infection control, and dietary services.
Findings
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.
Deficiencies (7)
F 0600: The facility failed to protect Resident #44 from physical abuse by another resident. The incident was isolated with minimal harm.
F 0645: The facility failed to ensure Resident #35's PASARR screening accurately reflected a diagnosis of depression.
F 0677: The facility failed to provide nail care for Resident #7, who was dependent on staff for personal hygiene.
F 0690: The facility failed to provide proper urinary catheter care and maintain the catheter bag below the bladder level for Resident #111.
F 0695: The facility failed to administer oxygen according to physician orders for Residents #6, #24, and #111, including inappropriate oxygen flow settings.
F 0806: The facility failed to accommodate food allergies and preferences for Residents #257 and #41, serving foods containing allergens or disliked items without substitution.
F 0880: The facility failed to ensure enhanced barrier precautions were followed for Residents #111 and #24, and failed to follow infection control practices during medication administration for Resident #46 and wound care for Resident #111.
Report Facts
Residents reviewed for ADLs: 5
Residents reviewed for respiratory therapy: 4
Residents reviewed for transmission based precautions: 7
Residents reviewed for medication administration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Witnessed abuse incident and involved in catheter care and wound care with infection control deficiencies. |
| LVN #14 | Licensed Vocational Nurse | Administered medications via gastrostomy tube without gown and unaware of enhanced barrier precautions. |
| RN #9 | Registered Nurse | Prepared medications with bare hands and failed to follow infection control practices. |
| CNA #6 | Certified Nursing Assistant | Observed providing oxygen and assisting Resident #6; involved in dietary tray delivery for Resident #41. |
| Dietary Aide #12 | Dietary Aide | Responsible for plating meals and checking tray cards; acknowledged errors in allergy accommodations. |
| Dietary Manager | Dietary Manager | Oversaw dietary staff and tray card printing; acknowledged need for double checking allergies and preferences. |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding expectations for care, infection control, and dietary compliance. |
| Medical Doctor #5 | Medical Doctor | Provided clinical expectations for oxygen therapy and infection control practices. |
| Infection Preventionist | Infection Preventionist | Acknowledged lack of staff training and signage on enhanced barrier precautions. |
| CNA #20 | Certified Nursing Assistant | Failed to wear gown and gloves during transfer and linen removal for Resident #24 on enhanced barrier precautions. |
| DSD | Director of Staff Development / Wound Care Nurse | Performed wound care but failed to perform hand hygiene between glove changes. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the inappropriate prescribing and administration of psychotropic medication, specifically Divalproex sodium, to Resident 1 without determining the appropriate indication for use.
Complaint Details
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.
Findings
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.
Deficiencies (1)
F 0758: The facility failed to follow policies regarding safe prescribing and administering of psychotropic medication by giving Divalproex sodium to Resident 1 without determining the appropriate indication for use. This increased the risk of serious side effects including nausea, vomiting, headaches, liver complications, tardive dyskinesia, and mood changes.
Report Facts
Medication administration dates: 3
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided information about medication administration and diagnosis for Resident 1 | |
| Registered Nurse (RN) 2 | Reviewed Resident 1's Order Summary Report and discussed side effects of Divalproex sodium | |
| Licensed Vocational Nurse (LVN) 1 | Administered Divalproex sodium and communicated with nurse practitioner to discontinue medication | |
| Licensed Vocational Nurse (LVN) 2 | Discussed appropriate use of Divalproex sodium as anticonvulsant and psychotropic medication | |
| Licensed Vocational Nurse (LVN) 3 | Reported concerns from Resident 1's responsible party about mood changes and medication use |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow policies and procedures for safe and appropriate prescribing and administering of psychotropic medication, specifically Divalproex sodium, for one sampled resident.
Complaint Details
The complaint investigation found that Divalproex sodium was administered to Resident 1 without a valid diagnosis of seizure disorder, increasing risk of side effects. The resident's responsible party requested discontinuation, which was ordered by the nurse practitioner.
Findings
The facility failed to ensure that Divalproex sodium was prescribed and administered with an appropriate indication for use for Resident 1, who was not diagnosed with any seizure disorder. This failure increased the resident's risk of serious side effects including nausea, vomiting, headaches, liver complications, tardive dyskinesia, and changes in mood, behavior, and thought processes.
Deficiencies (1)
Failure to follow policies and procedures regarding safe and appropriate prescribing and administering of psychotropic medication (Divalproex sodium) without determining appropriate indication for use.
Report Facts
Medication administration dates: 3
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 2 | Registered Nurse | Interviewed regarding Resident 1's Order Summary Report and medication side effects |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 1's Medication Administration Record and medication indication |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Administered Divalproex sodium and communicated with nurse practitioner for discontinuation |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Provided information on appropriate medication administration and indication |
| Licensed Vocational Nurse 3 | Licensed Vocational Nurse | Reported concerns from Resident 1's responsible party about medication administration |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with care planning and documentation standards following an unwitnessed fall resulting in a fracture and other changes in resident conditions.
Findings
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.
Deficiencies (2)
F 0657: The facility failed to develop and implement a comprehensive care plan for Resident 1's fractured right arm after an unwitnessed fall on 7/24/24. This failure could lead to complications such as skin breakdown, pain, and acute compartment syndrome.
F 0658: The facility failed to meet professional standards by not completing change of condition assessments for Resident 1 after a fall with fracture and for Resident 2 after changes in urine patterns and blood in urine.
Report Facts
Deficiencies cited: 2
BIMS score: 15
Dates of incidents: Jul 24, 2024
Dates of incidents: Jul 28, 2024
Dates of incidents: Jul 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) 1 | Interviewed regarding lack of care plan and change of condition assessments | |
| Director of Nursing (DON) | Interviewed regarding facility expectations for care planning and documentation |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with care planning and professional standards of quality following an unwitnessed fall resulting in a fracture for Resident 1 and changes in condition for Resident 2.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 1's fracture and did not complete required change of condition assessments for Resident 1 and Resident 2, resulting in incomplete documentation and potential risk to residents.
Deficiencies (2)
Failure to develop and implement a comprehensive person-centered care plan for Resident 1's fractured right arm after an unwitnessed fall on 7/24/24.
Failure to complete change of condition assessments for Resident 1 after an unwitnessed fall with fracture and for Resident 2 after changes in urine patterns and blood in urine.
Report Facts
Deficiencies cited: 2
BIMS score: 15
Date of fracture: Jul 24, 2024
Date of inspection: Aug 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding care plan and change of condition assessments for Resident 1 and Resident 2 |
| DON | Director of Nursing | Interviewed regarding facility expectations for care planning and change of condition assessments |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 22, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care and infection control practices at Valley Skilled Nursing Center.
Findings
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.
Deficiencies (2)
F 0684: The facility failed to ensure Licensed Vocational Nurses notified the physician and rechecked blood glucose within 15 minutes for a resident with a low blood glucose level of 55 mg/dl, contrary to facility policy.
F 0880: The facility failed to implement an effective infection prevention program by using disinfectant wipes that did not kill Clostridium difficile bacteria, increasing risk of infection transmission.
Report Facts
Blood glucose level: 55
Isolation duration: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Interviewed regarding failure to notify physician and recheck blood glucose | |
| Director of Nursing (DON) | Interviewed regarding hypoglycemia policy and infection control procedures | |
| Infection Preventionist (IP) | Interviewed regarding use of disinfectant wipes | |
| Housekeeping (HK) | Interviewed regarding cleaning practices and disinfectant wipe use |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow professional standards of practice related to hypoglycemia management and infection control procedures.
Complaint Details
The complaint investigation found substantiated failures in hypoglycemia management and infection control practices, with potential harm to residents.
Findings
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.
Deficiencies (2)
Failure to notify physician and recheck blood glucose within 15 minutes for Resident 2 with hypoglycemia.
Failure to use disinfectant wipes effective against Clostridium difficile, risking spread of infection.
Report Facts
Blood glucose level: 55
Isolation duration: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding failure to notify physician and recheck blood glucose |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies on hypoglycemia management and infection control |
| Infection Preventionist | Infection Preventionist | Interviewed regarding use of disinfectant wipes and infection control practices |
| HK | Housekeeping | Interviewed regarding cleaning practices and use of disinfectant wipes |
Inspection Report
Routine
Deficiencies: 9
Date: Jul 28, 2023
Visit Reason
Routine inspection of Valley Skilled Nursing Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to provide timely written notification of hospital transfers to residents and representatives, incomplete individualized care plans for psychotropic medications, failure to follow fluid restriction orders, medication administration errors, unlabeled medications, improper food texture preparation, unsanitary kitchen conditions, improper food storage, and inadequate room sizes for residents.
Deficiencies (9)
F0623: Facility failed to provide timely written notification to residents, representatives, and Ombudsman about hospital transfers for two sampled residents.
F0656: Facility failed to develop and implement a complete, individualized care plan for psychotropic medications for one sampled resident.
F0658: Facility failed to ensure professional standards of practice in medication administration for two residents, including failure to check blood pressure before giving antihypertensive and undocumented diagnosis for psychotropic medication.
F0755: Facility failed to provide pharmaceutical services to meet resident needs when medications were not obtained or administered timely for one resident after admission.
F0761: Facility failed to ensure drugs and biologicals were labeled properly and stored securely; multiple residents' medications and inhalers lacked resident identifiers.
F0805: Facility failed to prepare food in appropriate texture for 12 sampled residents, serving regular texture peaches instead of chopped for mechanical soft diets and scalloped potatoes with chunks instead of pureed.
F0812: Facility failed to ensure safe and sanitary food preparation and storage practices, including lack of air gap for prep sink, torn refrigerator gaskets, dust and debris in kitchen and storeroom, broken equipment, expired food, and improper food storage.
F0814: Facility failed to properly dispose of garbage as trash was found on the ground around one dumpster.
F0912: Facility failed to provide minimum room size of 80 square feet per resident in 18 of 34 rooms, potentially limiting privacy and space.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 5
Residents affected: 12
Residents affected: 39
Rooms: 18
Inspection Report
Routine
Deficiencies: 10
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident transfers, care planning, medication administration, pharmaceutical services, food preparation, sanitation, and resident room space.
Findings
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.
Deficiencies (10)
Failure to provide timely written notification to residents and representatives about hospital transfers.
Failure to individualize psychotropic medication care plan for Resident 1.
Failure to assess blood pressure prior to administering Lisinopril to Resident 94.
Failure to document medical diagnosis for Bipolar Disorder for Resident 3 receiving Risperidone.
Failure to provide medications for Resident 93 upon admission resulting in missed doses.
Failure to label eye drops and inhalers with resident identifiers.
Failure to prepare food in appropriate texture for residents on mechanical soft and pureed diets.
Failure to maintain sanitary conditions in kitchen including torn refrigerator gaskets, dust and debris on surfaces, broken equipment, expired food, and improper food storage.
Failure to properly dispose of garbage with trash found on ground around dumpster.
Failure to provide minimum room size of at least 80 square feet per resident in 18 rooms.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 5
Residents affected: 12
Residents affected: 39
Rooms: 18
Inspection Report
Routine
Deficiencies: 18
Date: Apr 15, 2022
Visit Reason
Routine state inspection survey of Valley Skilled Nursing Center to assess compliance with healthcare regulations and standards.
Findings
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.
Deficiencies (18)
F 0584: The facility failed to maintain safe and comfortable environment when window sills were separating from the wooden frame exposing nails and splinters in two resident rooms, placing residents at risk of injury and temperature exposure.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for five residents, including failure to care plan dentures, hospice status, dressing changes, and catheter care.
F 0658: The facility failed to ensure professional standards of practice when staff did not follow physician's order to administer continuous oxygen to a resident, risking respiratory distress.
F 0693: The facility failed to provide care consistent with professional standards for a resident with a gastrostomy tube when tube feeding and dressing changes were not performed as ordered, risking infection and inadequate nutrition.
F 0695: The facility failed to provide safe respiratory care when oxygen tubing was not changed as ordered for a resident, risking respiratory infection.
F 0732: The facility failed to post nursing staffing information daily at the beginning of each shift for two days, limiting transparency of staffing levels.
F 0757: The facility failed to adequately monitor a resident on bupropion for medication side effects, risking serious adverse effects.
F 0759: The facility had a medication error rate of 55.56% during observed medication passes, including failure to inform residents of medications administered and missing medications.
F 0801: The Food and Nutrition Director failed to effectively monitor dietary service operations, resulting in unclean kitchen areas, lack of staff competency evaluations, and failure to follow recipes and communicate diet orders.
F 0802: Dietary staff failed to safely and effectively carry out food and nutrition service functions including improper sanitizer temperature, thermometer calibration, and recipe adherence, risking foodborne illness.
F 0804: The facility failed to provide appetizing food at appropriate temperatures according to residents' preferences, with some foods served below recommended temperatures.
F 0806: The facility failed to honor a resident's food preference by serving beef despite documented dislike, risking decreased food intake.
F 0808: The facility failed to follow a physician's prescribed diet order for a resident, resulting in the resident receiving the wrong diet texture during lunch.
F 0812: The facility failed to ensure safe and sanitary food preparation and storage practices including lack of air gap in sinks, missing soap at handwashing sink, unclean kitchen areas and equipment, improper food storage in trash bags, and staff storing personal items in food storage areas.
F 0814: The facility failed to properly dispose of garbage and refuse with trash found surrounding dumpsters and lids not closed, risking pest attraction.
F 0842: The facility failed to ensure complete and accurate documentation of medical records for a resident, including incomplete assessments and vital signs documentation, resulting in delayed treatment.
F 0880: The facility failed to maintain an effective infection control program by not documenting review of COVID-19 screening questionnaires for visitors and staff for 14 days and failure of hospice nurse to disinfect blood pressure cuff between residents, risking infection transmission.
F 0912: The facility failed to provide rooms with at least 80 square feet per resident in 18 of 34 rooms, potentially limiting privacy and adequate space.
Report Facts
Medication errors: 15
Rooms below minimum square footage: 18
Residents affected by room size: 34
Days without screening review signature: 14
Residents with deficient care plans: 5
Residents affected by medication error: 2
Residents affected by oxygen administration failure: 1
Residents affected by gastrostomy care failure: 1
Residents affected by respiratory care failure: 1
Residents affected by dietary service deficiencies: 53
Residents affected by incomplete documentation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 5 | Licensed Vocational Nurse | Named in deficient documentation and assessment for Resident 58 |
| LVN 1 | Licensed Vocational Nurse | Named in window sill hazard and medication error findings |
| LVN 2 | Licensed Vocational Nurse | Named in medication error and missing medication for Resident 30 |
| LVN 4 | Licensed Vocational Nurse | Named in medication error for Resident 8 |
| FND | Food and Nutrition Director | Named in multiple dietary service deficiencies |
| DON | Director of Nursing | Named in multiple findings including infection control and documentation |
| ADON | Assistant Director of Nursing | Named in dietary and medication order communication findings |
| CNA 3 | Certified Nursing Assistant | Named in incomplete vital signs documentation for Resident 58 |
| HN | Hospice Nurse | Named in infection control failure for not disinfecting blood pressure cuff |
Inspection Report
Routine
Deficiencies: 16
Date: Apr 15, 2022
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements including resident care, environment, medication administration, dietary services, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including environmental hazards with broken window sills, incomplete and inaccurate resident care plans, medication administration errors, inadequate dietary service oversight and food safety practices, incomplete infection control measures, and insufficient documentation of resident assessments. Several residents were at risk due to these deficiencies.
Deficiencies (16)
Facility failed to maintain safe and comfortable environment due to broken window sills exposing nails and splinters, and allowing outside air in resident rooms.
Failed to develop and implement comprehensive person-centered care plans for five sampled residents, including missing care plans for dentures, hospice status, tube feeding site dressing, and foley catheter care.
Failed to ensure professional standards of practice in oxygen administration for one resident, including failure to administer continuous oxygen as ordered.
Failed to provide care consistent with professional standards for gastrostomy tube feeding, including failure to change tube feeding and dressing as ordered.
Failed to provide safe and appropriate respiratory care by not changing oxygen tubing as ordered.
Failed to post nurse staffing information daily at the beginning of each shift for two out of four days observed.
Failed to ensure Food and Nutrition Director effectively monitored dietetic service operations including staff competency evaluations and kitchen sanitation.
Failed to ensure dietary staff competency and adherence to food safety practices including proper sanitizer temperature, thermometer calibration, and recipe adherence.
Failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures, with residents reporting cold food and one vegetable served below recommended temperature.
Failed to honor resident food preferences when beef was served to a resident who disliked beef.
Failed to follow physician prescribed diet order for one resident, resulting in serving mechanical soft diet instead of regular diet.
Failed to ensure safe and sanitary food preparation and storage practices including lack of air gap in sinks, missing soap at handwashing sink, unclean kitchen equipment and areas, use of trash bags as food liners, and storage of personal items in food storage areas.
Failed to dispose of garbage and refuse properly with trash found surrounding dumpsters and lids not closing properly.
Failed to ensure complete and accurate documentation of medical records including incomplete resident assessments and vital signs documentation, and copying and pasting progress notes without updating.
Failed to maintain an effective infection prevention and control program including lack of documented review of COVID-19 screening questionnaires for visitors and staff, and failure of hospice nurse to disinfect blood pressure cuff between residents.
Failed to provide rooms with at least 80 square feet per resident in 18 out of 34 rooms, potentially affecting privacy and space.
Report Facts
Medication errors: 15
Rooms below minimum square footage: 18
Residents affected by room size deficiency: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 5 | Licensed Vocational Nurse | Named in inaccurate and incomplete documentation of Resident 58's condition |
| LVN 4 | Licensed Vocational Nurse | Named in medication administration errors for Resident 8 |
| LVN 2 | Licensed Vocational Nurse | Named in medication administration errors for Resident 30 |
| FND | Food and Nutrition Director | Named in failure to monitor dietary services and kitchen sanitation |
| HN | Hospice Nurse | Named in failure to disinfect blood pressure cuff between residents |
| DON | Director of Nursing | Named in oversight of infection control and documentation deficiencies |
| ADON | Assistant Director of Nursing | Named in medication administration and dietary communication |
| CNA 3 | Certified Nursing Assistant | Named in failure to document vital signs for Resident 58 |
| DA 1 | Dietary Aide | Named in failure to wash hands properly |
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