Vale Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 1 was free from physical abuse when Resident 2 hit Resident 1 with a cane during an encounter in the resident hallway. This failure resulted in Resident 1 sustaining a skin abrasion on the left arm.

Inspectors wroteBased on interview and record review, the facility failed to protect residents in the facility from potential physical abuse when Certified Nursing Assistant 1 (CNA1) was accused of deliberately slapping one resident (Resident 1) on the left arm and the facility failed to maintain documentation of a thorough abuse investigation and failed to notify the responsible party (RP) for Resident 1 of the allegation as required by facility policy. This failure resulted in placing all residents in the facility at risk of physical abuse and resulted in the RP for Resident 1 feeling alarmed. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement adequate supervision and interventions to prevent a resident-to-resident physical altercation for two of two sampled residents (Resident 1 and Resident 2), when Resident 2 entered Resident 1's room and punched Resident 1 in the face. This failure resulted in redness to Resident 1's face and caused feeling upset, and had the potential to result in serious physical injury and psychosocial harm including fear and emotional distress. During a record review of Resident 1's Face Sheet dated on 3/17/26, the Face Sheet indicated Resident 1 was admitted to the facility in September 2024 with diagnoses of malignant neoplasm (cancer) of rectum and depression (serious mental health condition characterized by persistent sadness and a loss of interest). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for one out of three sampled residents (Resident 1), to identify risk and develop a plan to help prevent Resident 1 from leaving the facility without authorization and unannounced. This failure resulted in Resident 1 eloping from the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to report Resident 2's verbal abuse and threat of harm against Resident 1 (one of three sampled residents) to the State Agency, local law enforcement, and/or the Long-Term Care Ombudsman (Resident advocate for rights and care in long-term facilities). This failure had the potential to place residents at risk for further abuse and psychosocial harm. During a record review of Resident 1's Face Sheet (resident demographic and clinical summary), Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, Facility 2 failed to document Resident 1's needs that could not be met by Facility 2 and the reasons why Resident 1's transfer or discharge was necessary. Facility 2 failed to appropriately communicate information concerning Resident 1's condition to Facility 1 prior to sending Resident 1 back to Facility 1. Facility 2 staff failed to properly admit Resident 1 to Facility 2 and then had Resident 1 transported back to Facility 1 from Facility 2, without properly discharging Resident 1 (from Facility 2) or having his medical needs assessed. This failure had the potential to result in a lapse in care when Resident 1 was sent back to Facility 1 from Facility 2 within a seven hour period on the same day. [...]

Inspectors wroteBased on observations and interviews, the facility failed to repair a moderate dent in the wall in Resident 107's room. This deficient practice had the potential to result in the resident not feeling or having a safe and/or homelike environment.

Inspectors wroteBased on observation, interview and record review, for two sampled residents (Resident 15 and 184), the facility failed to provide podiatry referrals to treat their long toe nails. This failure did not provide necessary services for treatment and foot care to these residents. During a review of Resident 15's Face Sheet dated 7/24/25, the Face Sheet indicated Resident 15 was admitted to the facility in November 2023. During a review of the Resident 15's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 4/25/25, it indicated Section B indicated Resident 15 had clear speech, able to express ideas and wants, and has the ability to understand others. Section C indicated Resident 15's a BIMS (Brief Interview for Mental Status-a standardized cognitive assessment tool) score: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1. One Breyna or Budesonide-Formoterol-Fumarate inhaler labeled only with a room number was found in medication cart 2 (an inhaler is a device used for delivering medicines into the lungs through breathing; Breyna is the brand name of Budesonide-Formoterol-Fumarate inhaler, and is a medication indicated for the treatment of breathing difficulties). 2. Two opened bottles of Refresh eyedrops (lubricating eye drops designed to soothe and relieve dry, irritated eyes) were found in medication cart 4. 3. [...]

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure that Resident 53 was provided with up-to-date annual dental services. This deficient practice had the potential to result in the resident experiencing pain, infection or difficulty eating which could lead to potentially decreased nutritional intake and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe, sanitary storage of food when:Multiple opened food items stored in the dry storage and refrigerators did not have open dates and use-by dates. Paper bag with food labeled 7/14 stored in the refrigerator had directions give to resident next day This failure had the potential to place all residents getting meals from the kitchen to be at risk for foodborne illness potentially leading to hospitalization or death. 1. During an observation and concurrent interview on 7/21/25 at 8:50 a.m., in the kitchen, refrigerator #2 had an opened box of cheesecake, with no open date and no used-by-date. The Registered Dietician (RD)stated he does not know when it was opened. RD stated opened refrigerated cheesecake was good for five days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control program when:1. The specimen refrigerator (a specimen refrigerator is a specialized cooling unit used to store various biological samples collected from patients, such as urine, stool, blood, or tissue) was observed to be stored in the same room with the ice container for residents' consumption. 2. Station 2 medication storage room drawer was found to be disorganized and contained medications mixed with specimen sample containers, central line dressing kit, needles and socks stored together. (a specimen container is used to store various biological samples collected from patients, such as urine, stool, blood, or tissue; Central Line Dressing kits are used for very clean resident dressing changes). [...]

Inspectors wroteBased on observations and interviews, the facility had three Resident rooms (Rooms 35, 41 and 43) with multiple beds that provided less that 80 square feet (sq. ft) per Resident who occupied these roomsThis deficient practice had the potential to result in inadequate space for the delivery of care to each Resident in each of these rooms and/or for storage of the Resident's belongings.

Inspectors wroteBased on interview and record review, the facility failed to update the code status (a medical term that indicates a patient's wishes regarding resuscitation and life-saving measures in the event of a medical emergency) for Resident 193. This deficient practice had the potential to result in the resident receiving treatments they may not want which could prolong their suffering or interventions inconsistent with their values and/or preferences.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a grievance for one of 36 sampled residents (Resident 38). This resulted in Resident 38's grievance to go unresolved. During a review of Resident 38's Facesheet (information containing contact details, brief medical history at a glance), the Face Sheet indicated, Resident 38 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/1/25, indicated Resident 38 had a brief interview for mental status or BIMS score of 15 (BIMS score of 13-15 indicates intact cognition). During an interview with Resident 38 on 7/21/25 at 12:03. p.m., Resident 38 stated my 500 dollars was stolen a few months ago and nothing has been done about it. [...]

Inspectors wroteBased on observation, interview and record review, for one of three sampled residents (Resident 200) who smoked, the facility failed to ensure a baseline care plan was developed to address Resident 200's smoking. This failure had the potential to result in the lack of interventions to promote safe smoking. During a review of Resident 200's RFS, the RFS indicated Resident 200 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (infection in the bone), severe sepsis (serious condition resulting from the body's response to infection, can lead to tissue damage and death if not treated promptly), and generalized anxiety disorder (mental health condition, persistent and excessive worry about various aspects of life). During an observation and interview on 7/22/25 at 4:42 p.m. with Resident 200, there was an open pack of cigarettes on the overbed table. [...]

Inspectors wroteBased on observation, interview and record review, for two sampled residents (Resident 199 and 200), the facility failed to ensure an environment free of accident hazards and failed to ensure residents receive adequate supervision when:1. Resident 199 left the facility unsupervised. This failure had the potential to result in significant risks to resident's safety.2. Resident 200 had cigarettes at the bedside. This failure had the potential to result in fire hazards. 1. During a review of Resident 199's Resident Face Sheet (RFS), the RFS indicated Resident 119 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), other non-toxic encephalopathy (brain disease), congestive heart failure and pleural effusion (fluid buildup around the lungs). During an interview on 7/21/25 at 10 a.m. [...]

Inspectors wroteBased on interview and record review, for one of three (Resident 112) sampled residents reviewed for behavioral health services, the facility failed to follow the psychiatrist's recommendation when Complete Blood Count (CBC, a common blood test that measures various components of your blood that included red blood cells, white blood cells, hemoglobin, etc. ), Basic Metabolic Panel (BMP, blood test that measures glucose, calcium, electrolytes, etc. to detect conditions such as liver and kidney disease and diabetes) and Urinalysis (UA, used to detect and manage disorders such as urinary tract infection, kidney disease and diabetes) and Culture and Sensitivity (C&S, used to diagnose urinary tract infection and guide antibiotic therapy) were not conducted. This failure had the potential to result in undetected abnormal blood levels due to current treatment. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure Resident 91 was updated regarding the status of her power wheelchairThis deficient practice had the potential to result in a significant impact on the resident's independence, quality of life, physical and mental health. During a review of Resident 91's Face sheet, dated 7/24/25, the Face sheet indicated, an initial admission date of 11/3/2018 and latest return date of 7/20/25. During a review of Resident 91's Face sheet, dated 7/24/25, the Face sheet indicated, Resident 91 had diagnoses to include: [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide call system (allows patients to request assistance from healthcare staff, typically nurses, by activating a call button or other alerting device. These systems are crucial for patient safety and efficient care delivery, enabling patients to quickly summon help when needed) to Resident 107. This deficient practice had the potential to result in resident having trouble accessing help for medication needs basic comfort or hygiene needs to prevent falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to track, find, replace, and follow up with two of two Residents (Resident 2 and Resident 3) whose dentures were lost at the facility. This failure resulted in two Residents not having their teeth to eat and talk which impacted their dignity and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice when: 1. For one of four sampled residents (Resident 3), the Interdisciplinary Team ' s (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) recommendation for Psychology (Psych) Consult related to an abuse allegation was not referred by Social Services (SS) Department. This failure had the potential to put Resident 3 ' s safety at risk and could lead to abuse re-occurrence and resident feeling depressed, angry, and vulnerable. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer medications timely for one of three sampled residents (Resident 1), when multiple medications for Resident 1 were administered after the ordered administration time. This failure had the potential for exacerbating Resident 1's health condition and compromising their overall health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications and COVID (a virus like the cold or flu) test kits were discarded when they were kept with ready to use medications in medication storage areas. This failure had the potential to result in residents receiving abnormal COVID test results, less potent or less effective doses of the medication which can lead to new health problems or adverse reactions.

Inspectors wroteBased on observation, interview, medical record and document review, the facility failed to provide services for activities of daily living for 2 (Resident 36 and 73) of 35 sampled residents when: 1. For Resident 73, fingernails were long and had black debris under the fingernails. 2. For Resident 36, feet were dry and toenails long. 3. For Resident 36, nursing staff did not get resident up in his wheelchair for a substantial period of time. These failures resulted in basic needs necessary for a quality of life not being met.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 178), the facility failed to respond to a pharmacist's Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident) recommendations when facility did not act upon pharmacy recommendations for Resident 178's psychoactive medications behavior and side effects monitoring and Lisinopril pulse monitoring. These failures had the potential for missed opportunities to prevent, identify, report, and resolve medication-related problems, medication errors, and/or other irregularities for Residents 178.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 05/21/24, three medication errors were observed out of thirty-five opportunities for two out of three residents, resulting in an error rate of 8.57%. This failure had the potential to result in more than minimal changes in the health and safety of Residents 78 and 155's conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe, sanitary storage of food when: 1. A thawed pork loin tied closed with a disposable glove was found on a dirty plastic platform and was not labeled with a thaw or use by date, 2. The same thawed pork loin was later found in the freezer and red liquid was leaking from the package. This failure had the potential to place all residents getting meals from the kitchen to be at risk for foodborne illness potentially leading to hospitalization or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide accurate pain assessment and pain management for one of 60 sampled residents (Resident 18) when Resident 18's left foot pain was not accurately and regularly assessed using an appropriate pain scale (numerical expression of pain severity out of ten, 0, no pain, 1-3 mild pain, 4-7 moderate pain and 8-10 severe pain) and pain medications were not provided in a timely manner. This failure resulted in Resident 18 having 9/10 to 10/10 left foot pain which was not relieved for over one hour and was not accurately assessed during administration of pain medications delaying additional pain interventions.

Inspectors wroteBased on observations and interviews, the facility had three Resident rooms (Rooms 35, 41 and 43) with multiple beds that provided less that 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each residents in each of these rooms and/or for storage of the resident's belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 3) from physical abuse when Resident 2 attempted to hit Resident 3 with Resident 2 ' s walker. The failure to protect Resident 3, a wheelchair dependent resident, from Resident 2, a resident with known aggressive behaviors, caused Resident 3 to slide off her wheelchair to the floor and had the potential to cause Resident 3 emotional and/or psychological distress.

Inspectors wroteBased on observation, interview, and record review, for one of four sampled residents (Resident 2), the facility failed to evaluate the effectiveness of the care plan and update as needed to include measurable objectives and timeframes to meet Resident 2 ' s immediate care and psychosocial needs. This deficient practice resulted in a care plan that did not accurately reflect specific medical interventions necessary to meet the resident ' s current nursing care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was referred to and provided Podiatry Services. This deficient practice resulted in Resident 1 having pain and at risk of injury because of his thick, long toenails to left foot.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two residents (Resident 17, Resident 133) with a gastrostomy feeding tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) received adequate nutrition and fluids when: 1. Resident 17's tube feeding was not administered according to physician order, the dietician recommendations were not communicated to the physician, and his weights were not monitored in three of the preceding six months. 2. Resident 133's tube feeding was not administered according to physician order, and the dietician recommendations were not communicated to the physician. These failures had the potential to result in undesirable weight loss or weight gain, dehydration, and malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain staff competency records for four of four sampled licensed staff: Licensed Vocational Nurse 3 (LVN 3), Licensed Vocational Nurse 4 (LVN 4), Registered Nurse 1 (RN 1), and Registered Nurse (RN 2). This failure had the potential to result in inadequate and/or inappropriate nursing care for any of the 176 residents.

Inspectors wrote4. During a review of Resident 18's Physician's orders dated [DATE], the order indicated resident was on a prescription mouthwash, Peridex, two times a day. During a concurrent observation and record review on [DATE] at 10:20 a.m., a bottle of Peridex prescription mouthwash was on Resident 18's bedside table. The label indicated the name of a resident, not Resident 18's name, at the top of the label, with black lines across the resident name. During an interview on [DATE] at 10:20 a.m. with Certified Nursing Assistant 7 (CNA 7), CNA 7 stated she had used the prescription mouthwash with the scratched label to clean Resident 18's mouth that morning. During an interview with Registered Nurse Supervisor (RNS) on [DATE] at 10:13 a.m., stated medication belonging to another resident should not be left at Resident 18's bedside, or used for Resident 18. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its medication error rate did not exceed five percent. There were eight medication errors out of 25 opportunities for error that totaled 32 percent (%) error rate when: 1. Resident 35 received four medications more than one hour after the scheduled administration time: metoprolol (used to lower blood pressure and treat heart failure), Xarelto (a blood thinner used to prevent clot formation which can cause heart attacks and strokes), hydrochlorothiazide (used to increase urination), hydrocodone (used for pain control). 2. Resident 170 received four medications more than one hour after the scheduled administrations time: [...]

Inspectors wrote5. A review of Resident 97's face sheet, undated, indicated Resident 97 was admitted in 2019, with diagnoses of chronic kidney disease, diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs), and dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning). A review of Resident 97's Prescription Order, dated [DATE], indicated three units of Novolog U-100 Insulin, (an insulin preparation with a concentration of 100 Units per milliliter) was to be injected before meals, three times a day at 6:45 a.m., 11:45 a.m., and 4:45 p.m. The Order indicted the medication was needed for treatment of Resident 97's diabetes mellitus. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use proper food handling techniques when in the kitchen during tray line, the hair for two dietary staff was not completely restrained with a hairnet. This failure had the potential to result in foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control policies and procedures were followed when: 1. One employee did not perform hand hygiene per protocol when doffing and donning gloves when providing direct care for one (Resident 56) of 35 sampled residents. 2. One employee did not wear appropriate Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) as required in the area for persons under investigation for infection with COVID (yellow zone) when caring for one (Resident 92) of 35 sampled residents. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assist one (Resident 38) of 35 sampled residents with bathing according to her preferences. This failure had the potential to result in emotional distress and decreased self-esteem from not receiving showers for two years.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician for two weeks when one (Resident 13) of 35 sampled residents developed a wound on the buttock. The failure to notify the physician resulted in delay of treatment and had the potential to result in delayed healing and exacerbation of the wound.

Inspectors wroteBased on interview and record review, the facility failed to update a comprehensive nutrition care plan that described services to be furnished for one (Resident 17) of 35 sampled residents. The failure to have a care plan which described Resident 17's current services and interventions for the nutritional needs associated with use of a gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) had the potential to result in weight loss, malnutrition, and complications such as pneumonia.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (Resident 21) of 35 residents received grooming assistance. This failure resulted in Resident 21 feeling uncomfortable due to long fingernails with black material under the nail tips and had the potential to result in scratches and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (Resident 173) of 35 residents received toenail care assistance according to the Resident's preferences. This failure had the potential to result in decreased self-esteem, decreased ability to wear shoes comfortably, and be scratched by the long toenails.

Inspectors wroteBased on interview and record review the facility failed to respond to a pharmacist's medication regimen review recommendation for one (Resident 136) of 35 residents for more than 30 days. The failure to respond to the recommendation for a gradual dose reduction of the medication aripiprazole (a psychotropic medication, a medication that affects brain activities associated with mental processes and behaviors) had the potential to result in adverse side effects from continued use for Resident 136 such as stroke, seizures, and suicide.

Inspectors wroteBased on interview and record review, the facility failed to accurately document entries for two of two sampled residents (Resident 106 and Resident 128) on the Skilled Nursing Facility Advanced Beneficiary Notice (ABN). This failure resulted in incomplete and inaccurate records.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two of three sampled residents (Resident 106 and Resident 128) after they were discharged from Medicare Part A services and continued to live in the facility. This deficient practice resulted in Residents 106 and 128 and their responsible parties/representatives being uninformed about their potential liability for payment and related standard claim appeal rights.

Inspectors wroteBased on observation and interview, the facility had three resident rooms (35, 41, and 43) with multiple beds that provided less than 80 square feet per resident who occupied these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents who occupied each room, or for storage of the residents' belongings.