Inspection Reports for Valley View Village
2571 Guthrie Ave, Des Moines, IA 50317, United States, IA, 50317
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 24, 2025, found deficiencies related to failure to follow a resident’s end-of-life treatment preferences as indicated on the Iowa Physician Orders for Scope of Treatment (IPOST). Earlier inspections showed a pattern of deficiencies involving resident safety during transfers, infection control practices, medication administration, care plan updates, and documentation. Several complaint investigations were substantiated, including issues with improper resident transfers causing injury, inadequate supervision leading to falls, and incomplete skin assessments. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring issues in resident care and safety, with some periods of correction followed by new deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
139% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
79 residents
Based on a November 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 1
Nov 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident rights regarding advance directives and end of life treatment preferences, specifically reviewing adherence to Iowa Physician Orders for Scope of Treatment (IPOST).
Findings
The facility failed to ensure that resident preferences for end of life treatments were followed as indicated on the IPOST for one resident. Staff did not present the IPOST to EMS during a crisis, resulting in intubation despite the resident's Do Not Intubate status.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure resident preferences for end of life treatments were followed as indicated on the IPOST. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | RN | Involved in CPR initiation and communication with EMS |
| Staff B | Educational Nurse | Assessed resident and reported EMS intubation |
| Staff C | CNA | Found resident unresponsive and was distressed |
| Director of Nursing | DON | Confirmed resident code status and discussed policy |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Nov 24, 2025
Visit Reason
The inspection was conducted as a result of investigation of Complaints #1733496-C, #1733497-C and Facility Reported Incident #2633651-I from October 6 to October 7, 2025.
Findings
The facility failed to ensure resident preferences for end of life treatments were followed as indicated on the Iowa Physician Orders for Scope of Treatment (IPOST) for one resident reviewed. Specifically, Resident #2, who was a full code with Do Not Intubate (DNI) status, was intubated by EMS despite the resident's wishes.
Complaint Details
The investigation was based on complaints and a facility reported incident. The complaint was substantiated as the facility did not follow the resident's advance directive orders during a crisis situation.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident preferences for end of life treatments were followed as indicated on the Iowa Physician Orders for Scope of Treatment (IPOST). | SS = D |
Report Facts
Census: 79
Complaint numbers: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | RN | Involved in CPR initiation and communication with EMS during Resident #2's emergency |
| Staff B | Educational Nurse | Assessed Resident #2 and reported EMS intubation despite DNI status |
| Staff C | CNA | Found Resident #2 unresponsive and was present during the emergency |
| Director of Nursing | DON | Confirmed Resident #2's code status and discussed facility policy and events |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 7, 2025
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance with health requirements.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective June 7, 2025.
Inspection Report
Routine
Census: 70
Deficiencies: 4
May 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to Minimum Data Set (MDS) submissions, accuracy of resident assessments, care plan completeness, and infection prevention and control practices at Valley View Village nursing home.
Findings
The facility failed to submit timely MDS assessments for some residents, inaccurately coded an anticoagulant drug on an MDS, and did not update care plans to include pertinent medications, pressure ulcers, or transfer techniques for several residents. Additionally, the facility failed to follow Enhanced Barrier Protection (EBP) practices for residents with indwelling medical devices and open pressure injuries.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to submit the Minimum Data Set (MDS) in a timely manner for 2 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to code an anticoagulant drug accurately on the Minimum Data Set (MDS) for 1 of 4 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update Care Plans for 3 of 18 residents reviewed to include pertinent medications, pressure ulcers, and transfer techniques. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow Enhanced Barrier Protection (EBP) practices for residents with an indwelling medical device and an open pressure injury for 2 of 2 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 2
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Signed MDS assessments for Residents #28 and #65 |
| Staff B | Certified Nursing Assistant (CNA) | Observed performing catheter and peri-care without gown |
| Staff C | Certified Nursing Assistant (CNA) | Observed performing catheter and peri-care without gown |
| Staff D | Registered Nurse | Observed performing wound care without gown |
| Staff E | Assistant Director of Nursing and Infection Preventionist | Observed wound care and provided interview on EBP practices |
| Staff F | Registered Nurse | Explained Pocket Care Plan updates and email communication |
| Staff G | Physical Therapy | Explained resident transfer assistance level |
| Staff H | Certified Occupational Assistant | Explained resident transfer assistance level |
| Staff I | Physical Therapy Assistant | Explained resident transfer assistance level |
| Administrator | Reported awareness of MDS and care plan gaps and staffing issues |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 4
May 8, 2025
Visit Reason
The inspection was conducted as the facility's Annual Recertification survey from May 5, 2025 to May 8, 2025 to assess compliance with federal regulations.
Findings
The facility was found deficient in timely submission and accuracy of Minimum Data Set (MDS) assessments, updating care plans with pertinent resident information, and adherence to Enhanced Barrier Protection (EBP) infection control practices for residents with indwelling devices and pressure injuries.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to submit Minimum Data Set (MDS) in a timely manner for 2 of 3 residents reviewed (Resident #28 & #65). | Level D |
| Failed to code an anticoagulant drug accurately on the Minimum Data Set (MDS) for 1 of 4 residents reviewed (Resident #17). | Level D |
| Failed to update Care Plans for 3 of 18 residents reviewed (#R17, R54, R195) to include pertinent medications, side effects, pressure ulcer, and transfer technique. | Level D |
| Failed to follow Enhanced Barrier Protection (EBP) practices for residents with an indwelling medical device and an open pressure injury for 2 of 2 residents reviewed (Residents #77 and #195). | Level D |
Report Facts
Residents reviewed for MDS timely submission: 3
Residents reviewed for MDS medication coding: 4
Residents reviewed for care plan updates: 18
Residents reviewed for infection control: 2
Facility census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Signed MDS assessments for Residents #28 and #65 |
| Staff B | Certified Nursing Assistant | Observed performing catheter care without gown for Resident #77 |
| Staff C | Certified Nursing Assistant | Observed performing catheter care without gown for Resident #77 and commented on gown use |
| Staff D | Registered Nurse | Observed performing wound care without gown for Resident #195 |
| Staff E | Assistant Director of Nursing and Infection Preventionist | Observed wound care and provided interview on EBP practices |
| Staff F | Registered Nurse | Explained care plan update process and Pocket Care Plan use |
| Staff G | Physical Therapy | Interviewed regarding transfer assistance for Resident #195 |
| Staff H | Certified Occupational Assistant | Interviewed regarding transfer assistance for Resident #195 |
| Staff I | Physical Therapy Assistant | Interviewed regarding transfer assistance for Resident #195 |
| Administrator | Reported awareness of MDS and care plan deficiencies and EBP practices |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 17, 2025
Visit Reason
A revisit of the survey ending March 5, 2025 was conducted on April 16, 2025 to April 17, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 21, 2025.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Mar 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the improper transfer of Resident #2, which resulted in a ligament injury when the resident was lowered to the floor without proper use of a gait belt and assistance.
Findings
The facility failed to ensure the safety of Resident #2 during transfers, leading to an injury caused by improper transfer techniques by CNA students who did not use a gait belt and did not follow care plan instructions for two-person mechanical lift transfers. The resident sustained a ligament injury requiring emergency room evaluation and ongoing pain management.
Complaint Details
The complaint investigation found that Resident #2 was improperly transferred by CNA students without using a gait belt, resulting in the resident being lowered to the floor with her right leg bent and caught under her, causing a ligament injury. The injury was substantiated with medical and event reports confirming the harm and improper transfer technique.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure safety during resident transfer resulting in actual harm to Resident #2 due to improper transfer without gait belt and inadequate assistance. | Level of Harm - Actual harm |
Report Facts
Census: 72
Pain medication frequency: 4
Pain medication frequency: 3
Pain medication frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Assisted in lowering Resident #2 to the floor and provided statements regarding the transfer incident |
| Staff B | Certified Nurse Aide (CNA) | Observed transferring Resident #2 using mechanical lift on 3/4/25 |
| Staff C | Certified Nurse Aide (CNA) | Observed transferring Resident #2 using mechanical lift on 3/4/25 |
| Student #1 | Involved in improper transfer of Resident #2 without gait belt, provided written statement | |
| Student #2 | Involved in improper transfer of Resident #2 without gait belt, provided written statement | |
| Administrator | Verified care plan and student training regarding transfer procedures | |
| Assistant Director of Nursing | Provided information about Resident #2's injury history | |
| Physician Assistant | Provided medical assessment and pain management details for Resident #2 |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Mar 5, 2025
Visit Reason
The inspection was conducted as a result of complaint investigations #124083-C and 125536-C and facility reported incidents #126991-I and 126992-I, which were substantiated.
Findings
The facility failed to ensure the safety of Resident #2 during transfers, resulting in a ligament injury when the resident was improperly transferred by students without use of a gait belt. The resident required two staff members and a full body mechanical lift for transfers but was transferred unsafely, causing harm. The facility's policy requires gait belts for transfers, which was not followed.
Complaint Details
Complaints #124083-C and 125536-C were substantiated. Facility reported incidents #126991-I and 126992-I were substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents, resulting in harm to Resident #2 during transfer. | SS=G |
Report Facts
Resident census: 72
Pain medication frequency: 4
Audit frequency: 4
Audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Named in transfer incident and injury finding |
| Staff B | Certified Nurse Aide (CNA) | Observed transferring Resident #2 with Staff C |
| Staff C | Certified Nurse Aide (CNA) | Observed transferring Resident #2 with Staff B |
| Assistant Director of Nursing | Provided statement about resident injury and pain | |
| Physician Assistant | Provided medical assessment and pain management details | |
| Administrator | Provided statement about CNA students and care plan adherence |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 8, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility will be certified in compliance effective August 8, 2024, based on acceptance of the credible allegation of compliance and plan of correction. The DPNA was effectuated from June 28, 2024 to August 7, 2024.
Inspection Report
Re-Inspection
Census: 75
Capacity: 75
Deficiencies: 1
Jul 23, 2024
Visit Reason
This inspection was a revisit of the survey ending May 30, 2024, conducted from July 22 to July 23, 2024, to verify correction of previously cited deficiencies related to infection prevention and control.
Findings
The facility failed to maintain acceptable infection control practices by placing a glucometer on surfaces without a barrier for one of three residents reviewed. The Assistant Director of Nursing acknowledged the failure to use barriers as expected. The facility policy requires use of barriers and proper infection control procedures during blood glucose monitoring.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have acceptable infection control practices by placing a glucometer on the medication cart and resident's tray table without a barrier. | SS=E |
Report Facts
Census: 75
Total Capacity: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Observed placing glucometer without barrier; specifically reeducated for infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged failure to use barriers and infection control expectations |
Inspection Report
Routine
Census: 75
Deficiencies: 2
May 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to staffing competencies for behavioral health needs and infection prevention and control practices.
Findings
The facility failed to provide sufficient properly trained staff to implement care plan interventions for a resident with self-injurious behavior, resulting in actual harm. Additionally, the facility failed to follow infection prevention protocols during blood glucose monitoring and dining service.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide sufficient staff with competencies to meet behavioral health needs, resulting in harm to a resident with self-injurious behavior. | Level of Harm - Actual harm |
| Failed to implement infection prevention and control program properly, including failure to place barriers during blood glucose monitoring, improper use of sharps containers, and improper cleaning and storage of glucose monitors. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 3
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Therapeutic Activities Coordinator | Observed failing to redirect resident during chewing behavior |
| Staff C | CNA | Observed failing to redirect resident and interviewed about staffing concerns |
| Staff D | CNA | Observed failing to redirect resident and interviewed about staffing concerns |
| Staff F | Culinary Assistant | Did not acknowledge resident's request for help |
| Staff G | RN | Noted resident chewing behavior and intervened |
| Director of Nursing | DON | Acknowledged expectations for redirection and staffing limitations |
| Director of Food and Nutrition Services | Offered resident water and dessert during observation |
Inspection Report
Routine
Census: 75
Deficiencies: 8
May 30, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, medication management, activities of daily living assistance, behavioral health needs, medication regimen review, food safety, medical record confidentiality, and infection prevention and control.
Findings
The facility failed to follow physician orders for medication administration timing, failed to obtain ordered daily weights, and failed to provide nail care for residents. The facility also lacked sufficient trained staff to meet behavioral health needs, failed to document rationale for declining a medication dose reduction, failed to perform proper hand hygiene during food service, failed to protect resident medical records confidentiality, and failed to implement proper infection control practices during blood glucose monitoring and dining service.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to follow physician orders for medication administration timing for 3 of 18 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain ordered daily weights and notify physician for Resident #67. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary nail care for Resident #67. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient trained staff to meet behavioral health needs for Resident #37, resulting in harm. | Level of Harm - Actual harm |
| Failed to document rationale for declining a Gradual Dose Reduction for Resident #42. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform hand hygiene to prevent foodborne illness during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect medical records confidentiality for 2 residents by leaving medication carts unattended with visible medication lists. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement infection prevention and control during blood glucose monitoring and dining service. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication administration: 19
Residents reviewed for ADL: 1
Residents reviewed for behavioral health: 1
Residents reviewed for medication regimen: 5
Residents affected by hand hygiene deficiency: 1
Residents affected by confidentiality deficiency: 2
Residents affected by infection control deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in wound care observation for Resident #30 |
| Staff B | Therapeutic Activities Coordinator | Observed during behavioral health observation for Resident #37 |
| Staff C | Certified Nursing Assistant (CNA) | Observed during behavioral health observation for Resident #37 |
| Staff D | Certified Nursing Assistant (CNA) | Observed during behavioral health observation for Resident #37 |
| Staff F | Culinary Assistant | Observed during food service hand hygiene deficiency |
| Staff G | Registered Nurse (RN) | Observed during behavioral health observation for Resident #37 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including medication administration, nail care, behavioral health, infection control |
| Administrator | Interviewed regarding weight monitoring and nail care for Resident #67 | |
| Director of Food and Nutrition Services | Interviewed regarding food service hand hygiene |
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 7
May 30, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #120533-C.
Findings
The facility was found deficient in multiple areas including medication administration timing, failure to follow physician orders, inadequate nail care, insufficient staffing for behavioral health needs, failure to document pharmacist recommendations, food safety violations, confidentiality breaches of resident records, and infection control practices.
Complaint Details
Complaint #120533-C was substantiated as part of the annual recertification survey conducted from May 28, 2024 to May 30, 2024.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=G: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to follow physician orders for medication administration times and treatment plans for residents #20, #30, and #67. | SS=D |
| Facility failed to provide necessary grooming services, specifically nail care, for Resident #67. | SS=D |
| Facility failed to provide sufficient and properly trained staff to implement care plan interventions for Resident #37 with self-injurious behavior, resulting in harm. | SS=G |
| Facility failed to document rationale for declining gradual dose reduction for psychotropic medication for Resident #42. | SS=D |
| Facility staff failed to perform hand hygiene and proper food handling during meal service. | SS=E |
| Facility failed to protect resident medical records from unauthorized viewing on medication carts for Residents #41 and #26. | SS=D |
| Facility failed to follow infection control procedures during blood glucose monitoring for Residents #13, #26, and #55, including lack of barriers, improper lancet disposal, and improper cleaning of glucose monitors. | SS=E |
Report Facts
Census: 75
Total Capacity: 75
Medication administration times: 7
Oral hygiene charting entries: 9
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Draper | Executive Director | Signed the Statement of Deficiencies on 06/19/2024 |
| Staff A | Registered Nurse | Observed during wound care for Resident #30 |
| Staff B | Therapeutic Activities Coordinator | Observed during behavior observation of Resident #37 |
| Staff C | Certified Nursing Assistant | Observed during behavior observation of Resident #37 |
| Staff D | Certified Nursing Assistant | Observed during behavior observation of Resident #37 |
| Staff F | Culinary Assistant | Observed during meal service and behavior observation of Resident #37 |
| Staff G | Registered Nurse | Observed during behavior observation of Resident #37 |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 28, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on January 28, 2024, related to facility certification compliance.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance effective January 28, 2024.
Inspection Report
Census: 75
Capacity: 75
Deficiencies: 2
Dec 28, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safety standards related to accident hazards and supervision to prevent falls, following incidents involving two residents who experienced falls due to staff errors.
Findings
The facility failed to maintain a safe environment for two residents, resulting in falls caused by improper use of a lift device sling and leaving a resident unattended in the bathroom. The incidents caused minimal harm but highlighted deficiencies in staff supervision and adherence to safety protocols.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff maintained a safe and secure environment for residents, resulting in falls due to improper sling placement during transfers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision, leaving a resident unattended in the bathroom which led to a fall. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 75
BIMS score: 12
BIMS score: 11
Date of fall incident: Nov 20, 2023
Date of fall incident: Sep 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding the fall incidents and confirmed improper sling placement and leaving residents unattended |
| Director of Nursing | Director of Nursing (DON) | Confirmed staff failed to properly place the sling device leading to a resident fall |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Dec 28, 2023
Visit Reason
The inspection was conducted as a result of investigation of complaints #115535-C, #115708-C, and #116328-C between December 21, 2023 and December 28, 2023.
Findings
The facility failed to ensure staff maintained a safe and secure environment for residents, resulting in falls due to improper use of lift device slings. Two residents (#3 and #5) were identified with falls related to staff errors in sling placement and leaving a resident unattended, causing injury but no fractures.
Complaint Details
The visit was complaint-related based on investigation of complaints #115535-C, #115708-C, and #116328-C. The complaint was substantiated as staff failed to properly place lift device slings and left a fall-risk resident unattended, resulting in falls and injuries.
Deficiencies (1)
| Description |
|---|
| Failure to ensure resident environment remains free of accident hazards and residents receive adequate supervision and assistance devices to prevent accidents, evidenced by improper sling placement causing resident falls. |
Report Facts
Resident census: 75
Complaints investigated: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding fall incidents and confirmed residents at fall risk should not be left unattended. |
| Director of Nursing | Confirmed staff failed to properly place sling device leading to resident fall. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 25, 2023
Visit Reason
The document is a Plan of Correction submitted following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was certified in compliance effective September 24, 2023, based on acceptance of the credible allegation and Plan of Correction. No specific deficiencies are detailed in the report.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 1
Aug 24, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care standards, specifically focusing on skin assessments and wound care for residents, including Resident #5 who had wounds and skin concerns.
Findings
The facility failed to ensure staff completed and documented skin assessments for Resident #5 who had wounds and skin concerns. Documentation and follow-up assessments were incomplete or missing, particularly for skin tears and wounds, despite policies requiring weekly assessments and wound management documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete and document skin assessments for Resident #5 with wounds and skin concerns. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 70
Wound measurement: 6
Wound measurement: 5.5
Wound measurement: 1.5
Wound measurement: 1
Wound measurement: 2
Wound measurement: 2.5
Wound measurement: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Documented wound assessments and discontinuations for Resident #5's wounds |
| Staff B | Licensed Practical Nurse (LPN) | Reported nurses completed weekly skin assessments and documented in medical records |
| Staff D | Registered Nurse (RN) | Reported on skin assessment procedures and CNA involvement |
| Staff E | Licensed Practical Nurse (LPN) | Reported on skin assessments and wound management, confirmed missing assessments for Resident #5 |
| Staff F | Assistant Director of Nursing (ADON) | Performed wound assessments on pressure areas and bigger wounds; went on leave and left position |
| Staff G | Registered Nurse (RN) | Observed removing dressing and noted open wound on Resident #5 |
| Staff C | Registered Nurse (RN) | Reported on facility's skin and wound assessment documentation system |
| Director of Nursing (DON) | Director of Nursing | Confirmed missing skin assessments and described staff education efforts |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Aug 24, 2023
Visit Reason
The inspection was conducted as a Complaint Survey investigating complaints #112065-C, 114193-C, 114648-C, and 114872-C, as well as a facility-reported incident #111733-I, from August 21 to August 24, 2023.
Findings
The facility failed to ensure staff completed and documented skin assessments for one of four residents reviewed who had a wound or skin concern (Resident #5). Several skin wounds and assessments were documented with gaps in follow-up and documentation. Complaints #112065-C, 114193-C, and 114872-C were substantiated, while complaint #114648-C and incident #111733-I were unsubstantiated.
Complaint Details
Complaints #112065-C, 114193-C, and 114872-C were substantiated. Complaint #114648-C and facility reported incident #111733-I were unsubstantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure staff completed and documented skin assessments for Resident #5 who had a wound or skin concern. | SS=D |
Report Facts
Resident census: 70
Complaints investigated: 4
Facility reported incident: 1
Residents reviewed for skin assessments: 4
Resident #5 wound measurements: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Propes | Executive Director | Signed the report on 9/19/23 |
| Staff A | Licensed Practical Nurse (LPN) | Documented wound assessments and discontinued wound assessments for Resident #5 |
| Staff B | Licensed Practical Nurse (LPN) | Reported nurses completed weekly skin assessments and documented in resident's electronic medical record |
| Staff D | Registered Nurse (RN) | Reported resident skin assessments completed weekly and communication with physician and family |
| Staff E | Licensed Practical Nurse (LPN) | Reported nurse completed skin assessments and communicated with CNA and other staff |
| Staff F | Assistant Director of Nursing (ADON) | Completed wound assessments on pressure areas and bigger wounds; went on leave |
| Director of Nursing (DON) | Director of Nursing | Confirmed wound assessment practices and staff education |
| Staff C | Registered Nurse (RN) | Reported on wound assessment documentation and process changes |
Inspection Report
Plan of Correction
Deficiencies: 0
May 1, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
The facility was certified in compliance effective April 7, 2023, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Routine
Census: 75
Deficiencies: 4
Mar 2, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident rights, medication administration, grooming and bathing assistance, and feeding tube care at Valley View Village nursing home.
Findings
The facility failed to treat a resident with dignity by not informing him of a prosthetic appointment, failed to follow professional standards in medication administration by leaving medication at bedside, failed to provide grooming and bathing assistance as scheduled, and failed to ensure the head of the bed was elevated during gastrostomy tube feeding.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to treat residents with dignity by not informing Resident #59 of a prosthetic appointment, causing him to miss it. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow professional standards of medication administration by leaving medication at bedside for Resident #50. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide grooming and bathing assistance for Resident #59 as scheduled. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the head of the bed was elevated during gastrostomy tube feeding for Resident #43. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 75
BIMS score: 15
BIMS score: 15
BIMS score: 5
Medication administration time: 8.25
Feeding rate: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Verified Resident #59 did not feel well and was unaware of prosthetic appointment |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding Resident #59 appointment and medication administration policies |
| Staff A | Registered Nurse (RN) | Acknowledged leaving medication at bedside for Resident #50 |
| Assistant Director of Nursing | Assistant Director of Nursing | Verified Resident #59 did not receive grooming assistance as scheduled |
| Staff C | Registered Nurse (RN) | Observed and administered gastrostomy tube feeding for Resident #64 |
| Social Services Director | Social Services Director | Accompanied DON during interview regarding Resident #59 appointment |
Inspection Report
Routine
Census: 75
Deficiencies: 5
Mar 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, medication administration, personal care, feeding tube care, and infection control at Valley View Village nursing home.
Findings
The facility was found deficient in multiple areas including failure to inform a resident about a scheduled prosthetic appointment, improper medication administration by leaving pills at bedside, inadequate grooming and bathing assistance, failure to maintain proper head-of-bed elevation during feeding tube use, and lapses in infection control practices such as not wearing gloves during blood sugar checks and insulin administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to treat resident with dignity by not informing him of a scheduled prosthetic appointment, causing him to miss it. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow professional standards of medication administration by leaving medication at bedside without ensuring resident took them. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide grooming and bathing assistance as scheduled, including help with shaving. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure head of bed was elevated 30-45 degrees during gastrostomy tube feeding. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff utilized infection control techniques including glove use and proper disinfection of glucometer machines during blood sugar checks and insulin administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 2
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Acknowledged leaving medication at bedside and failed to wear gloves during blood sugar check and insulin administration |
| Staff B | Registered Nurse (RN) | Verified resident did not feel well and was unsure if resident had advance notice of prosthetic appointment |
| Staff B | Certified Medication Aide (CMA) | Properly performed blood glucose check with glove use and disinfection |
| Staff C | Registered Nurse (RN) | Observed initiating and monitoring feeding tube care |
| Director of Nursing (DON) | Provided multiple clarifications and verified expectations regarding resident appointments, medication administration, feeding tube care, and infection control | |
| Assistant Director of Nursing | Verified resident did not get grooming assistance/shower as scheduled and staff should help with shaving |
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 5
Mar 2, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of complaints 110113-C, 110200-C, and 110279-C.
Findings
The facility was found to have deficiencies related to resident rights, professional standards of care, medication administration, assistance with activities of daily living, tube feeding management, and infection prevention and control. Two complaints were substantiated, and one was not substantiated.
Complaint Details
Complaints 110113-C and 110200-C were substantiated; complaint 110279-C was not substantiated.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to treat residents with dignity for 1 of 8 residents reviewed (Resident #59) by scheduling an appointment without his knowledge and failing to inform him, causing him to miss the appointment. | SS=D |
| Facility failed to follow professional standards of medication administration, leaving medication at bedside for Resident #50. | SS=D |
| Facility failed to provide grooming/bathing assistance for Resident #59 as scheduled. | SS=D |
| Facility failed to ensure head of bed elevation during gastrostomy tube feeding for Resident #43. | SS=D |
| Facility failed to ensure infection control practices including glove use and disinfection of glucometer machines, and failed to wear gloves during insulin administration for Resident #125. | SS=D |
Report Facts
Census: 75
Deficiencies cited: 5
Resident count reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in findings related to appointment scheduling, medication administration, and infection control |
| Staff A | Registered Nurse | Named in medication administration deficiency for leaving pills at bedside and insulin administration |
| Staff B | Registered Nurse and Certified Medication Aide | Named in infection control and medication administration findings |
| Staff C | Registered Nurse | Named in tube feeding administration and head of bed elevation findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 11, 2022
Visit Reason
The document is a plan of correction accepted following a survey ending October 5, 2022, certifying the facility in compliance effective November 11, 2022.
Findings
The facility submitted a credible allegation of compliance and plan of correction after the survey, resulting in certification of compliance effective November 11, 2022.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Oct 5, 2022
Visit Reason
An investigation of complaints #103331-C, #105402-C, and #106982-C, along with facility-reported incidents #104789-I and #107677-I, was conducted from September 26 to October 5, 2022.
Findings
The investigation found that complaints #103331-C and #106982-C were not substantiated, while complaint #105402-C was substantiated. Facility-reported incidents #104789-I and #107677-I were not substantiated. Deficiencies included failure to obtain a laboratory sample per physician orders for one resident and failure to ensure call lights were answered timely for residents.
Complaint Details
Complaint #105402-C was substantiated. Complaints #103331-C and #106982-C were not substantiated. Facility-reported incidents #104789-I and #107677-I were not substantiated.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to obtain a laboratory sample per physician orders for 1 of 5 residents reviewed for assessment and intervention (Resident #2). | Level D |
| Facility failed to ensure call lights were answered in a timely manner to meet the needs and ensure safety for 2 of 5 residents sampled for supervision and call lights (Residents #1 and #3). | Level D |
Report Facts
Residents reviewed: 5
Census: 68
Call lights unanswered: 2
Call light response times: 16.14
Call light response times: 25.2
Call light response times: 22.03
Call light response times: 15.56
Call light response times: 23.41
Call light response times: 26.21
Call light response times: 25.06
Call light response times: 18.03
Call light response times: 25.06
Call light response times: 25.09
Call light response times: 16.39
Call light response times: 18.38
Call light response times: 20.13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Wrote progress notes on 2/18/22 related to Resident #2's care |
| Staff C | Licensed Practical Nurse (LPN)/Health Unit Coordinator | Described lab order and verification process |
| Staff E | Medical Records/Quality Assurance | Discussed lab sheet process and inability to locate lab results |
| Staff F | Certified Nurse Aide (CNA) | Interviewed regarding Resident #1's call lights and care |
| Staff G | Certified Nurse Aide (CNA) | Interviewed regarding call light response |
| Staff H | Registered Nurse (RN) | Interviewed regarding call light log and response times |
| Staff I | Licensed Practical Nurse (LPN) | Interviewed regarding call light incidents |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 6
Oct 21, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of facility-reported incidents 98833-I and 100284-I, both of which were substantiated.
Findings
The facility was found deficient in several areas including reasonable accommodations for residents, care plan timing and revision, free of accident hazards, pharmacy services, food safety, and infection prevention and control. Specific issues included failure to provide call lights within reach, incomplete care plans, inadequate supervision and use of gait belts, inaccurate narcotic counts, improper food handling, and failure to follow infection control protocols.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide a call light within reach for residents. | SS=D |
| Failure to revise care plans to reflect actual care needs and conditions. | SS=D |
| Failure to provide adequate supervision and use gait belts during resident transfers. | SS=D |
| Failure to document narcotic counts accurately and reconcile medications. | SS=E |
| Failure to procure, store, prepare, and serve food in accordance with professional standards. | SS=D |
| Failure to establish and maintain an infection prevention and control program including proper use of PPE and hand hygiene. | SS=E |
Report Facts
Resident census: 67
Narcotic count discrepancies: 18
Narcotic count discrepancies: 30
Narcotic count discrepancies: 18
BIMS score: 3
BIMS score: 8
BIMS score: 1
BIMS score: 14
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 17, 2021
Visit Reason
Complaints #89337, #94976 and a Facility Self-Reported Incident #95783 were investigated by the Department of Inspections & Appeals on February 11-17, 2021.
Findings
The investigations of the complaints and the self-reported incident were completed with no substantiation found.
Complaint Details
Complaints #89337, #94976 and a Facility Self-Reported Incident #95783 were investigated with no substantiation.
Inspection Report
Routine
Census: 66
Deficiencies: 0
Nov 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 74
Deficiencies: 0
Jun 22, 2020
Visit Reason
A Covid 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Renewal
Census: 74
Deficiencies: 5
Feb 13, 2020
Visit Reason
The inspection was conducted as a recertification survey for Valley View Village, covering compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in several areas including comprehensive resident assessments, development and implementation of comprehensive care plans, food safety and sanitation practices, and infection prevention and control. Specific issues involved incomplete assessments, inadequate care plan updates, improper food handling, and failure to use barriers during glucose monitoring and insulin administration.
Deficiencies (5)
| Description |
|---|
| Failure to complete a comprehensive and accurate resident assessment using the Resident Assessment Instrument (RAI) for one of 18 residents reviewed. |
| Failure to follow resident care plans during transfers for 1 of 2 residents observed. |
| Failure to update and revise care plans with interventions and guidance for 1 of 18 residents reviewed. |
| Failure to ensure food service staff properly covered hair with hair nets while preparing and serving food. |
| Failure to establish and maintain an infection prevention and control program including use of barriers during glucose monitoring and insulin administration. |
Report Facts
Residents reviewed: 18
Residents observed: 2
Census: 74
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 1
Jan 14, 2020
Visit Reason
The inspection was conducted as an investigation of Facility Reported Incidents #86899, #87274, #87946 and Complaints #86896, #87400. The visit focused on evaluating the facility's compliance with regulations related to accident hazards and supervision.
Findings
The facility failed to report a fall for one of five residents reviewed, Resident #1, who experienced a fall resulting in a left hip fracture. The investigation revealed inadequate staff communication and failure to notify the charge nurse about the fall incident. The facility's care plan and fall risk policies were reviewed and updated accordingly.
Complaint Details
The investigation was triggered by complaints and facility reported incidents related to falls and supervision. The complaints were substantiated as the facility failed to report a fall and properly manage the resident's care following the incident.
Deficiencies (1)
| Description |
|---|
| The facility staff failed to report a fall for Resident #1, who sustained a left hip fracture after a fall. |
Report Facts
Facility census: 75
Total capacity: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Assessed resident after fall, did not receive fall report from aide |
| Staff B | Registered Nurse (RN) | Contacted physician, prepared resident for x-ray, failed to handle fall situation properly |
| Staff C | Certified Nurse Aide (CNA) | Prepared resident for x-ray |
| Staff D | Certified Nurse Aide (CNA) | Provided care during fall incident, failed to report fall to charge nurse |
| Staff E | Director of Nursing | Conducted investigation and stated proper notification procedures |
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