Park Valley Inn Health Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 3 of 5 medication carts ( Treatment Cart #1, Treatment Cart #2, and Nursing Cart #3) reviewed for medication storage. The facility failed on 07/21/2026 to ensure Treatment Cart #1 & #2 and Nursing Cart #3 were locked, and medications were secure and not accessible to other staff, residents or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (R#1) of 7 residents reviewed for falls. The facility failed to notify the NP from 6/12/26 through 6/14/26 when R#1's head injury worsened after her two incidents [PH1.1][SB1.2]on 6/11/26. R#1 was sent to the hospital on 6/15/26, diagnosed with traumatic subarachnoid hemorrhage and required care in the ICU. The facility failed to follow R#1's hospital discharge orders of discontinuing her Ticagrelor [PH2.1][SB2.2]when she returned to the facility on 6/18/26. R#1 was sent to the hospital and received stiches to her forehead because staff could not stop the bleeding from her laceration after sustaining a fall on 6/23/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (R#1) of 7 residents reviewed for pain management. The facility failed to accurately assess R#1's pain levels. This failure could place residents at risk of functional decline, untreated physiological complications and mental health deterioration.

Inspectors wroteBased on interview and record review, the facility failed to administer in a manner that enables it to resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 13 of 19 staff reviewed for in-services. The facility failed to in-service who were assigned to work in the memory care unit on 6/11/26 on abuse, neglect and exploitation, incidents and accidents and resident rights on 6/11/26. This failure could place residents at risk of repeat safety failures, escalating neglect, and sustaining avoidable injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for 1 (R#1) of 7 residents reviewed for incidents. The facility failed to report R#1's hematoma to left eyebrow area on 6/11/26 to the SSA. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise residents' comprehensive care plans for 1 (R#1) of 7 residents reviewed for care plans. The facility failed to timely review and revise R#1's care plan after her two incidents on 6/11/26 and one incident on 6/23/26. This failure could place residents at risk of not receiving treatment and care to meet residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal care for 1 of 5 residents (Resident #1) reviewed for ADL care. The facility failed to provide nail care to Resident #1, leaving the toenails thick, dirty, long, and discolored. This failure could place residents at risk of social embarrassment, isolation, infection, injury, pain, deterioration of health and a diminished quality of life.

Inspectors wroteBased on observation, interviews, record reviews and the comprehensive assessment of a resident, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for one (Resident #1) of four residents review for quality of care in that: The facility failed to ensure Resident #1 was wearing her Geri-sleeves as ordered to reduce the risk of injury. The facility failed to intervene appropriately when Resident #1 had a skin tear on her left lateral calf on 05/11/2026 which led to Resident #1 having another skin tear on her right posterior lower leg. The facility failed to ensure Resident #1's wound care was done as ordered when the dressing came off. These deficient practices placed Residents at risk for infection, injury and decreased quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1 ) of one Resident reviewed for transfers RN A and CNA B failed to properly transfer Resident #1 with a gait belt on 5/19/2026, they used Resident #1's pants to transfer her from the wheelchair to the bed. This failure place resident at risk of fall, injury and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 10 residents (Resident# 43, Resident #80, and Resident #114) reviewed for ADL care. The facility failed to ensure Resident# 43, Resident #80, and Resident #114 was groomed and did not have unwanted facial hair. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's bedside, toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 8 residents (Resident #16, Resident #22, and Resident #81 ) reviewed for resident call system .The facility failed to provide a working communication system, which was easily at reach, which would allow Resident #16, Resident #22, and Resident #81 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation, determine that drug records were in order, an account of all controlled drugs was maintained and periodically reconciled for 1 of 4 medication carts (Medication Cart #1-700 Hall) in the facility effecting 1 of 20 residents (Resident #105) reviewed for pharmacy services and failed to provide pharmaceutical services including procedures that assure the accurate acquiring of all drugs and biologicals by monitoring for expiration dates in 1 of 2 medication rooms reviewed for pharmacy storage. The facility failed to ensure LVN D and the LVN E accurately reconciled Resident #105's narcotic medication log when LVN D administered but did not sign for Resident #105's Hydrocodone-Acetaminophen 5-325 MG 1 tablet on 03/10/2026 at a.m. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 of 23 residents (Resident #2 and Resident #42) reviewed for infection control. The facility failed to ensure LVN C followed proper infection control procedures after completing the wound care for Resident #2, removing biohazardous trash from Resident #2's room and did not sanitize her hands after removing gloves and before touching clean supplies on her treatment cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a change in residents health status for 1 of 1 resident (Resident #1) reviewed for notification of changes. LVN B failed to immediately notify Resident #1's physician and Resident # 1's RP when CNA A reported to him that resident had skin tears to right hand and right elbow. This failure could place residents at risk of injury, hospitalization, and/or decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #1 & #2) of 16 residents reviewed for quality of care. The facility failed to ensure that the residents were cared for in a kind manner for Residents #1 and Residents #2 by walking away from the residents and not returning. The noncompliance was identified as PNC. The noncompliance began on 09/10/25 and ended on 09/17/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving necessary care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents were free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse when Resident #2 physically assaulted her on 09/27/25. The noncompliance was identified as PNC. The noncompliance began on 09/27/25 and ended on 09/30/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensives person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of four residents reviewed for care plans. The facility failed to ensure Resident #1's care plan intervention for needing assistance with eating was implemented on 08/06/25. This failure could place residents at risk of not receiving the appropriate care to meet their needs.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 5 of 7 residents (Resident's #2, #3, #4, #5, and #6) reviewed for care plans. 1. The facility failed to ensure that Resident #2's care plan was revised, updated, and individualized to address Resident #2's risk for dehydration. 2. The facility failed to ensure care plan interventions (1:1 and/or in room activities) were implemented and documented for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. These failures placed residents at risk of not receiving the appropriate care to meet their current needs.

Inspectors wroteIntake #557738 Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 7 of 29 residents (Resident #1, Resident #17, Resident #68, Resident #39, Resident #80, Resident #159, Resident #21) reviewed for infection control. 1. The facility failed to test all residents who had flu like symptoms. 2. The facility failed to put place residents on quarantine or droplet precautions when indicated. An IJ was identified on 01/15/25 at 4:45 pm. The IJ template was provided to the facility on [DATE] at 7:15 pm. The plan of removal was accepted on 01/17/25 4:52 pm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents environment remained free of accident and hazards to prevent avoidable accidents for 1 (Resident #28) of 1 resident reviewed for safe transfers. The facility failed to ensure mechanical lift #1 was removed from the floor after it was deemed out of order on 01/03/2025. The facility failed to ensure mechanical lift #2 was in working order prior to Resident #28's transfer. The mechanical lift fell on top of Resident #28 and Resident #28 fell to the floor from the lift which resulted in Resident #28 being transferred to the ER to be treated for a lumbar fracture and hemorrhage on 01/03/2025. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 01/15/2025 at 6:15 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. 1. The facility failed to ensure [NAME] I wore a hair restraint that full covered her hair on 01/14/2025 while preparing food. 2. The facility failed to ensure [NAME] I performed hand hygiene when preparing food on 01/14/2025. These failures could place residents at risk for health complications, foodborne illnesses and decreased a quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to accommodate the needs and preferences for 5 of 10 residents reviewed for accommodations. The facility failed to ensure that Residents #17, #39, #159, #80, and #94 had call lights in reach while lying in bed. This deficient practice could place residents at risk of injury, for not receiving timely care, and for not receiving nursing interventions. Findings Included: Resident #39 Record review of Resident #39's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic pain due to trauma, a contusion of head, wedge compression fracture 3rd lumbar vertebrae, rheumatoid arthritis, fracture of left femur and nasal bones, repeated falls, severe protein-calorie malnutrition, hypotension, and nausea. [...]

Inspectors wroteBased on observation, interviews and record review , the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, which included measurable objectives and time frames to meet the resident's mental and psychosocial need for three (Resident #3, Resident #73, and Resident #97) of six residents reviewed for care plans. The facility failed to update Resident #97's activity preferences were not updated after the quarterly assessment. The facility failed to update Resident #73's dental status and activity preferences were not updated after the quarterly assessment. The facility failed to implement a comprehensive care plan for Resident #3 within 21 days of admission on [DATE]. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity in an environment that promotes maintenance or enhancement of his or her quality of life for 4 of 31 residents (Resident #3, Resident #59, Resident #97, and Resident #15) reviewed for resident rights. 1. The facility failed to ensure Resident #3, Resident #59 and Resident #97 clothing were changed daily on (01/14/2025 through 01/17/2025). 2. The facility failed to ensure Resident #15's room was free of odors and cleaned daily or as needed on 01/14/2025. This failure placed all residents at risk for not receiving adequate care and diminished quality of life and embarrassment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the resident had a right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms and to use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for Resident #2 whose care was reviewed. in that: Resident #2 was in a wheelchair against the nurse's desk and a table in the dining room with the wheels locked prevented her from getting out of the wheelchair. These deficient practices affected 1 resident and had the potential to affect other residents who may be placed in restraints by contributing to restricted movement, a decline in ADL's function, and psychological distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their written policies and procedures were implemented regarding prohibiting and preventing abuse and neglect for 1 (Resident #95) of 6 residents reviewed for developing and implemented abuse and neglect policies. LVN T failed to report that Resident #95 was slapped on the shoulder by Resident #97 and failed follow incident procedures after she received report of incident on 01/14/2025. This deficient practice could place residents at risk of continued abuse, injury, trauma, and psychosocial harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one (Resident #159) of eight residents reviewed for nutrition status maintenance. The facility failed to obtain consistent weights of Resident #159. The facility failed to update the care plan to reflect the needs of Resident #159 The facility failed to keep accurate record of Resident #159's food intake. This failure could place residents at risk of further weight loss, malnutrition, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 5 residents (Resident #31 and Resident #35) reviewed for pharmaceutical services. The facility failed to remove discontinued controlled medications from the medication cart for Resident #31 and Resident #35. The facility failed to ensure proper reconciliation for drugs and investigate errors. This failure leaves residents vulnerable to medication errors. Resident #31 Record review of Resident #31's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to ensure LVN A documented Resident #1's unwitnessed fall, conducted neuros, and informed the oncoming nurse on 11/28/24. The aides continued to notify the nurses of Resident #1's pain and was not sent to the ER until the late evening on 11/29/24, where she was diagnosed with a hip fracture. The noncompliance was identified as PNC. The IJ began on 11/28/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed on 11/04/24 during breakfast time to protect Resident #1 from physical and emotional abuse by CNA B, who threw a cup on him with agitation. This failure could place residents at risk of serious injury and harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 4 residents (Residents #2 and Resident # 3) reviewed for quality of care. The facility failed to ensure Resident #2 and Resident #3's nebulizing mask and tubing, that were observed on 11/06/24, were not bagged for sanitation when not in use per the facility's policy. This failure could affect residents who received nebulizing treatment and place them at risk for respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, for 1 (Resident #1) of 4 residents reviewed for resident rights, in that: The facility failed to include Resident #1's HSP (Hospice) services in Resident #1's care planning process . The facility held an IDT meeting between 03/22/24 and 06/24/24 to discuss Resident #1's behaviors and alternative placement and did not invite and include Resident #1's HSP in the meeting. This failure could place residents at risk of not receiving appropriate interventions, treatments, and care.

Inspectors wroteBased on interviews and record reviews, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 (Resident #1) of 4 residents reviewed for hospice services, in that: The facility failed to immediately notify Resident #1's HSP about Resident #1's increase in aggressive behaviors and interfering or not allowing staff to provide care to some female residents behaviors and a need to transfer Resident #1 from the facility to due his behaviors from 03/22/24 through 06/24/24. This failure could place residents at risk of not receiving appropriate interventions, treatments, and care.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a person designated as the infection preventionist worked at least part-time at the facility for one (LVN A) of two infection preventionists reviewed. The facility did not have and infection preventionist who worked at least part-time at the facility from 01/01/24 through 01/21/24. This deficient practice could place residents at risk of cross contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for one of one facilities reviewed for nursing services. The facility failed to designate a DON from August 2023 to December 2023. This failure placed all resident at risk of decreased supervision and oversight of nursing related services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for one of one kitchens reviewed for food and nutrition services. The facility failed to ensure all foods were stored off the floor, labeled, dated and discarded prior to their use-by date. These failures placed residents at risk of foodborne illness.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure call lights were in reach for 2 of 8 residents (Residents #25 and #29) for resident rights. The facility failed to ensure Resident #25 and Resident #29 had access to their call lights. This failure placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse to the administrator of the facility and to the State Survey Agency for 2 of 2 (Resident #69 and Resident #203) residents reviewed for resident abuse. The facility failed to report an allegation of abuse to the State Survey Agency, received by LVN E on 10/13/2023, that Resident #203 hit Resident #69. This failure placed residents at risk for unidentified abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one of one allegations reviewed for resident abuse. The facility failed to ensure an allegation of abuse between Resident #69 and Resident #203 was thoroughly investigated. This failure placed residents at risk of unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment remained as free of accident hazards as possible for 1 of 8 (Resident #65) residents reviewed for quality of care. The facility failed to ensure Resident #65's did not possess an unsecured razor blade. This failure placed residents in the memory care unit at risk of injuries.

Inspectors wroteBased on interview and record review, the facility failed to provide food that accommodates residents' preferences for one (Resident #29) of 8 residents reviewed for food and nutrition services. The facility failed to re-assess Resident #29's preferences after severe weight loss (16.123%) over the course of 6 months. This failure could place all residents at risk for severe weight loss and frustration from not enjoying meals.

Inspectors wroteBased on interview and record review the facility failed to ensure to implement an effective discharge plan by not following their discharge planning policy and procedure for 1 of 2 residents reviewed (Resident #1) for discharge planning. The facility did not get the resident or representative a against medical advice form prior to the resident leaving the building per facility policy. This failure could place residents at risk of not receiving care and services to meet their needs.