Tice Valley Post Acute

Inspectors wroteBased on interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by qualified and competent staff which affect all 123 residents. This failure resulted in all 123 residents receiving social services care from unqualified staff. During an interview on 9/23/25, at 10:35 a.m., with Social Services Director (SSD), SSD stated they were the director of the social services department and were responsible for admission assessments, discharge planning. SSD stated the social services department assisted residents with dental, optometry, podiatry and psychiatric appointments to ensure residents' physical, mental and psychosocial needs were met. SSD stated they had been working since 5/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents 1-8, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services to maintain grooming and personal hygiene for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNAs) did not provide Resident 1 showers as scheduled by the facility. This failure placed Resident 1 at risk for poor hygiene, body odor, infection, and transmission of diseases. During a review of Resident 1's admission Record (AR), printed 3/25/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis (Kidney failure impossible to service without dialysis). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by qualified and competent staff which affected all 120 residents. This failure resulted in all 120 residents receiving social services care from unqualified staff. During an interview on 9/23/25, at 10:35 a.m., with Social Services Director (SSD), SSD stated they were the director of the social services department and were responsible for admission assessments, discharge planning. SSD stated the social services department assisted residents with dental, optometry, podiatry and psychiatric appointments to ensure residents' physical, mental and psychosocial needs were met. SSD stated they had been working since 5/2025. [...]

Inspectors wroteBased on observation, interview and medical record and document review, the facility failed to provide services for activities of daily living for 1 (Resident 50) of 8 sampled residents when: For Resident 50, fingernails were long and had black debris under the fingernails. These failures resulted in resident not having their hygiene maintained and had the potential to increase risk for infection.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to follow the hemodialysis (treatment to remove waste products and excess fluid from the blood when kidneys are not functioning properly) care plan for one (Resident 50) of eight sampled residents reviewed. This failure did not ensure a hemodialysis resident received the service consistent with professional standards of practice and a person-centered care plan.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate diet texture according to physician orders for two of three sampled residents (Resident 23 and 5) when both received a minced and moist meat texture instead of chopped. These failures resulted in Resident 5 and 23 experiencing a lower quality of life when they received a less advanced diet which was not to their documented preference. A review of Resident 23's admission record titled, admission Record, dated 9/25/25, indicated Resident 23 was admitted to the facility for senile degeneration of brain and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (Residents 9 and 69) out of eight sampled residents received appropriate catheter care per facility policy when there were inconsistent cleaning methods used by staff. This failure had the potential to result in increased risk of urinary tract infections for residents 9 and 69.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate safety measures and adequate supervision to prevent one of three residents (Resident 1) from slipping out of bed and falling on the floor during incontinence care. The failure to provide adequate measures to prevent a dependent resident from slipping off the bed and falling onto the floor during incontinence care, resulted in Resident 1 being transported to the emergency department for further evaluation, requiring 15 stitches to maintain closure of the laceration (cut) on the right lower leg, and fracturing (partial or complete break in the bone) their right shoulder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supplies stored in the Lexington medication storage room were appropriate for use when: 1. Ten Female Luer Lock Caps (a device used to seal syringes [pumps used for drawing up and expelling liquids or suspensions into the body]) were expired. 2. Two Statlock Catheter Stabilization Devices (designed to stabilize peripherally-inserted central catheters or PICCs [a long, thin tube inserted through an arm and passed through to the larger veins near the heart]) were expired. 3. One IV Catheter was expired. 4. One Kangaroo Feeding Bag Set (a spike, tubing, and bag for liquid nutrition delivery directly into the digestive tract) was expired. These failures had the potential for residents to receive expired, ineffective, and contaminated medications and treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a stock medication bottle of Senna (a laxative for short-term treatment of constipation) had a legible expiration date and was removed from resident use. These failures had the potential for the residents to receive expired and ineffective medication treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow kitchen practices that prevent cross-contamination and food borne illness when: 1. Chopping boards were in poor condition and stained; 2. Freezer temperature log did not have temperatures recorded for 6/15/24 and 6/16/24. These failures had the potential to cause food borne illness to a highly susceptible population of 117 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed infection control procedures for four of nine sampled residents (Residents 43, 326, 331, and 328) when facility did not ensure staff: 1. washed hands with soap and water after caring for resident rooms who had clostridioides difficile (c. diff, bacteria that causes diarrhea and inflammation of the colon which can be life-threatening), 2. used appropriate germicidal wipes to disinfect equipment after use on a resident with c. diff and, 3. were trained on infection control and hand hygiene techniques. This failure had the potential for the spread of c. diff through the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide hygiene care in a reasonable time for one of nine sampled residents (Resident 43) when Resident 43 had to wait in stool and urine for 45 minutes before staff could change the resident. This failure caused Resident 43 to feel dejected because she had to wait 45 minutes for assistance and had the potential for Resident 43 to be at risk of skin breakdown due to exposure to urine and stool.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate safety measures and adequate supervision to prevent one of two residents (Resident 1) from rolling out of bed and falling on the floor during a bed linen change. The failure to provide sufficient staff or adequate measures to prevent a dependent resident from rolling off the bed during a bed linen change, which resulted in Resident 1 being transported to the emergency department for evaluation after the fall caused a brief loss of consciousness and a headache which lasted over a week.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1's clinical record was accurately documented when Resident 1's right heel ulcer was documented in the Treatment Administration Record (TAR) as a right lower leg ulcer. This failure had the potential to result in uncoordinated care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 20 sampled residents (Resident 10 and Resident 48) received showers, bed baths and personal hygiene when: 1. Resident 10 did not receive showers or bed baths and had greasy hair and long fingernails with black matter underneath; and 2. Resident 48 had long nails with black matter underneath. These failures had the potential for Resident 10 and 48 to develop an infection from lack of proper hygiene and to injure themselves with long fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 29 sampled residents' (Resident 63 and 67) body weights were monitored according to physician's orders when Resident 63 and 67's body weight records were missing. This failure put Resident 63 and 67 at risk for not receiving appropriate evaluations, interventions and or modifications to manage the causes for nutritional risks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Oxygen (O2) and CPAP (a machine that helps maintain the airway remain open by providing a steady flow of air at constant pressure) physician orders were established and followed for one of 29 sampled residents (Resident 27) when resident 27 used O2 and CPAP as needed without physician orders. This failure had the potential for Resident 27 to receive the wrong dose of O2 and to use the CPAP at a wrong setting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate did not exceed five percent for one of four sampled residents (Resident 18). There were two medication errors out of 25 opportunities resulting in an eight percent (%) medication error rate when Resident 18 did not receive Amlodipine Besylate (medication for high blood pressure) and the wrong dose of Folic Acid (a vitamin supplement to help make red blood cells) was administered. This failure resulted in Resident 18 not receiving medications per physician orders and it had the potential for Resident 18 to experience uncontrolled high blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor room temperature for one of two medication storage rooms (Med room [ROOM NUMBER]) from 12/2021 through 1/2022. This failure had the potential to affect the potency and effectiveness of medications stored in Med room [ROOM NUMBER].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was attractive and palatable for one of five sampled residents (Resident 36) when over cooked, brown peas were served for lunch. This deficient practice had the potential to impact Resident 36's nutritional status.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow COVID-19 (a respiratory disease caused by the SARS-CoV-2 virus) infection procedures for one of one sampled resident (Resident 101) when Resident 101 was not tested for COVID 19 after admission from the acute care hospital and proper signage and Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards) was not provided. This practice had the potential for the spread of COVID-19 infections to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident room doorknob was properly working and tightly fastened to the door for one of 29 sampled residents (Resident 19) when Resident 19's room doorknob was loose. This failure had the potential for Resident 19 to experience a fall and avoidable injuries.

Inspectors wroteBased on interview and record review the facility failed to act upon consultant pharmacist's recommendations for Gradual Dose Reduction (GDR, stepwise tapering of a dose to determine if symptoms, conditions or risks can be managed by a lower dose or if the dose or the medication can be discontinued) for multiple psychotropic (medications that affect brain activity) medications and a diagnosis clarification for one of 29 sampled residents (Resident 33) when Resident 33's psychotropic medications' dosages remained unchanged for two consecutive months. This failure placed Resident 33 at risk to receive psychotropic medications at a higher dose.

Inspectors wroteBased on observation, interview, and document review, the facility failed to identify the indications for use of a psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication for one of one sampled resident (Resident 87) when specific behavior was not identified and clinical rationale was not documented for administering Quetiapine (an antipsychotic medication that affects brain activity associated with mental process and behavior). This failure did not ensure Quetiapine medication was an appropriate medication to treat Resident 87's medical diagnosis of Parkinson (a movement disorder that affects the ability to perform common daily activities).