Deficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
175% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
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 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 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, 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
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 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
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: 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: 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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