Inspection Reports for
Valley View Health & Rehabilitation

The complaint investigation was triggered by reports of rude and rough care by a Certified Medication Technician (CMT F) towards multiple residents, inadequate assistance with activities of daily living, and a resident smoking inside the facility despite oxygen use and prior warnings. The resident was found with multiple packs of cigarettes and lighters, admitted to smoking in his/her room and dining area, and was not adequately supervised despite policy requirements.

The facility failed to ensure residents were treated with dignity and respect by staff, provide adequate assistance with activities of daily living including grooming and nail care, and failed to provide adequate supervision to prevent a resident from smoking inside the facility despite oxygen use and multiple prior incidents.

The facility was found deficient in multiple areas including failure to provide adequate oral hygiene care, improper pressure ulcer care and documentation, unsafe resident transfers leading to injury, improper food handling and sanitation practices, lack of medical director attendance at QAPI meetings, and inadequate infection prevention and control practices.

The complaint investigation focused on Resident #333's pressure ulcer care and documentation. The resident had multiple hospital admissions and readmissions with worsening pressure ulcers. The facility failed to notify the physician or nurse practitioner of wound changes, did not implement ordered low air loss mattress, and did not update care plans or document wound care communications. The resident's pressure ulcers worsened to Stage IV, requiring hospital transfer and surgical debridement.

The facility failed to ensure proper assessment, documentation, and treatment of pressure ulcers for Resident #333, resulting in worsening pressure ulcers from admission through readmission, culminating in a Stage IV pressure ulcer. The facility did not obtain an order or implement a low air loss mattress as ordered, failed to notify the physician of wound changes, and did not update care plans or document communications adequately. The resident was eventually discharged to the hospital with a worsened stage IV pressure ulcer requiring surgical debridement.

The facility failed to provide adequate care to residents dependent on staff for ADLs, including failure to keep residents clean, dry, repositioned, and hydrated. Incontinence care was neglected, and urinary catheter care was insufficient, risking infections. Staff also failed to follow proper hand hygiene and glove use protocols, increasing infection risk. The facility census was 84.

The visit was complaint-related due to allegations of narcotic medication diversion by CMT A. The complaint was substantiated as CMT A admitted to ingesting narcotic medications from three residents. The local police department was notified and the staff member was terminated.

The facility failed to prevent misappropriation of narcotic medications from three residents by CMT A, who removed and ingested hydrocodone-acetaminophen pills while on duty. The issue was discovered during a pharmacist's random medication spot check, leading to suspension and termination of CMT A. The facility conducted in-services on abuse, neglect, and misappropriation and corrected the deficient practice.

The complaint investigation found that CNA A physically abused Resident #3 on 12/31/23 by holding down the resident's arms and pushing on the resident's chest while the resident hollered out. The abuse was witnessed by LPN B. CNA A was suspended immediately and terminated on 1/2/24. The facility conducted an investigation and educated all staff on abuse policies.

The facility failed to protect Resident #3 from physical abuse when CNA A was witnessed holding down the resident's arms and pushing on the resident's chest while the resident hollered out. The abuse was confirmed, CNA A was suspended and later terminated, and all staff were re-educated on abuse prevention policies.

The complaint was substantiated. Resident #1 filed a complaint about CNA A's treatment of Resident #2. Interviews and statements confirmed CNA A verbally abused Resident #2 by threatening to break the resident's hands and calling the police if the resident hit him again. CNA A was suspended on 5/8/23 and terminated on 5/12/23.

The facility failed to protect Resident #2 from verbal abuse by CNA A, who threatened to break the resident's hands if the resident hit him/her. The facility suspended and subsequently terminated CNA A and conducted a mandatory in-service for all staff on resident abuse/neglect. The non-compliance was corrected promptly.

The facility was found deficient in maintaining a clean and safe environment, timely notification of resident transfers to hospitals, proper urinary catheter care, posting of nurse staffing information, and adherence to infection prevention protocols including hand hygiene and medication administration practices.

The facility failed to complete significant change assessments for four residents, did not provide adequate personal hygiene care for three residents, failed to keep urinary catheter drainage bags off the floor for two residents, did not limit PRN psychotropic medication orders to 14 days or document gradual dose reductions for two residents, failed to offer bedtime snacks to residents, and did not ensure proper hand hygiene and infection control practices among staff.