Inspection Reports for
Valley View Health & Rehabilitation

The complaint investigation was substantiated, finding that staff were rude and forceful with residents, causing emotional distress. The facility failed to provide adequate care and supervision, including grooming, hygiene, and smoking policy enforcement.

The facility failed to ensure residents were treated with dignity and respect, as evidenced by rude and forceful care by staff. Additionally, the facility did not provide adequate assistance with activities of daily living and failed to maintain proper grooming and hygiene for dependent residents. The facility also failed to enforce smoking policies and provide protective oversight for residents on voluntary leave.

The facility failed to clearly identify a system to ensure the safe evacuation of three dependent bariatric residents during an emergency. The emergency preparedness plan and residents' care plans did not specify how staff would safely evacuate these residents, and staff were inconsistent about the number of staff required and evacuation methods.

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 facility failed to prevent misappropriation of narcotic pain medications by a certified medication technician who removed medications from three residents and admitted to ingesting them while on duty. The administrator was notified and corrective actions including termination of the staff member and in-services on abuse, neglect, and misappropriation were conducted.

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 facility failed to protect one resident from physical abuse by a CNA who was observed pushing and holding the resident's arms in a harmful manner. The abuse was substantiated, the CNA was terminated, and staff were educated on abuse and neglect policies. The deficiency was corrected by 1/2/24.

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 facility failed to protect a resident from abuse by a Certified Nurse Assistant (CNA), who threatened to break the resident's hands. The CNA was suspended and terminated, and a mandatory in-service training was conducted for all staff. The non-compliance was corrected on 5/8/23.

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 managing residents' personal funds, ensuring freedom from misappropriation, following physician orders for medications, and maintaining infection prevention and control protocols including COVID-19 measures. Several residents were affected by these deficiencies, and the facility had a census of approximately 70 residents during the survey.

The facility was found deficient in maintaining a safe, clean, and homelike environment, proper notification before resident transfer or discharge, catheter care, nurse staffing information posting, and infection prevention and control. Specific issues included strong urine odors, dust-covered vents, scuff marks, failure to notify residents or representatives of transfers, improper catheter care, lack of posted nurse staffing data, and inadequate infection control practices.

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 provide timely final accounting of resident personal funds upon discharge or death for two residents. The facility also did not submit required personal funds account balance reports and did not notify the Department of Social Services upon a resident's death as required.

The complaint involved allegations of abuse by Resident #1 toward other residents. The facility failed to report the allegations timely and did not notify law enforcement. The resident exhibited inappropriate sexual behaviors and caused harm to another resident. The complaint was substantiated based on interviews, record reviews, and observations.

The facility failed to report a resident's allegation of abuse to the state survey agency and law enforcement in a timely manner. Additionally, the facility failed to implement appropriate interventions to address the resident's behaviors and psychosocial needs, resulting in harm to another resident.

The facility failed to ensure adequate assistance with activities of daily living (ADLs) for several residents, resulting in poor hygiene and grooming. Additionally, the facility did not maintain an effective pest control program, with multiple observations of flies and other pests in resident areas.

The facility failed to notify a resident's guardian regarding a surgical procedure and failed to develop comprehensive care plans for two residents within the required timeframe. The facility also failed to ensure one resident received prescribed thyroid medication and did not fully vaccinate staff against COVID-19.

The facility failed to provide adequate monitoring and consistently implement care plan interventions to reduce fall risks for residents, resulting in multiple falls and injuries. Documentation and evaluation of falls and care plan updates were insufficient.

The facility failed to provide timely and complete written notices for resident transfers and discharges, including failure to notify the resident or their representative and to document discharge notices properly. The facility also did not comply with bed hold policy requirements and emergency discharge notification regulations.

The facility failed to maintain an infection control program compliant with federal regulations, including inadequate signage, improper use and storage of PPE, failure to perform hand hygiene, and improper handling of urinary catheter bags and testing equipment. Multiple observations and interviews revealed lapses in staff adherence to infection control policies and PPE protocols.

Complaint #MO00178131 regarding failure to provide CPR to a resident who was a full code and found unresponsive without pulse.

The facility failed to provide CPR to a resident who was unresponsive and without pulse or respirations, despite the resident being a full code. Staff did not initiate CPR or call 911, and the resident was found deceased without CPR intervention.

The facility failed to consistently implement and evaluate interventions to prevent falls for one resident, with a census of 69 residents at the time. The review showed multiple issues including lack of documentation of fall interventions, failure to notify physicians and families, and inadequate monitoring of the resident after falls.

The complaint investigation found that the facility did not meet the regulatory requirements for 30-day transfer/discharge notices. The deficiency was substantiated based on record review and interviews.

The facility failed to ensure that a resident's 30-day discharge notice included the location to which the resident was being discharged, the telephone number to call regarding appeal rights, and information on how to obtain and submit an appeal form. The facility census was 62 at the time of the survey.

The complaint investigation was substantiated based on interviews with residents, staff, and family members confirming that a CNA used profanity and was disrespectful to residents. Multiple grievances were filed by residents #2, #4, and #5 against CNA A for cursing and inappropriate behavior.

The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple complaints and interviews revealing that a CNA used profanity and exhibited disrespectful behavior toward residents. The facility acknowledged these issues and planned corrective actions.

The facility failed to ensure one resident remained free from misappropriation of property when staff stole the resident's debit card and charged $397.68 to the resident's account. The facility also failed to employ or engage staff with adverse actions to prevent abuse, neglect, misappropriation, and exploitation of residents.

The facility was found deficient in multiple areas including comprehensive assessment after significant change, ADL care, infection control, psychotropic drug use, bowel/bladder incontinence, and frequency of meals. Several residents were identified as affected by these deficiencies.

The facility failed to meet several fire safety requirements including delayed egress locking arrangements, sprinkler system maintenance, smoking regulations, and emergency electrical system maintenance. Deficiencies had the potential to affect residents in multiple smoke compartments.

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.

The complaint alleged abuse, neglect, exploitation, or mistreatment involving Resident #52 and others. The facility failed to report the allegations timely and adequately investigate. The complaint was substantiated based on interviews, record reviews, and observations.

The facility failed to ensure immediate reporting and proper investigation of alleged abuse and neglect. Deficiencies were found in professional standards of care, pressure ulcer prevention, infection control, medication management, and resident safety.

The facility failed to meet several Life Safety Code requirements including discharge from exits, kitchen equipment cleaning, fire alarm system installation, sprinkler system installation, corridor door latching, smoke barrier integrity, and smoking regulations. Deficiencies had the potential to affect residents, visitors, and staff.