Valencia Hills Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent resident to resident altercation for five (Residents: #20, #51, #126, #185, #192) of five residents reviewed. This failure resulted in three resident-to-resident physical altercations on one (500-unit) of five units. Findings Include:1. On 04/27/2026 at 10:52 AM, an observation was made of two residents yelling at each other in the dining room of the 500 units. An activities aid was sitting at the table with the two residents. A nurse and the medical records coordinator responded to the situation, after two minutes of the argument. At the same time, Resident #20 had walked over to resident #185, who was sitting in a wheelchair and watching television (TV). [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to serve food in accordance with professional standards for food service safety related to one of one dish washing machines was not operated per its specifications.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a comfortable, homelike and clean environment to include; 1. Resident room water temperatures not hot; 2. Shower room bathing equipment with bio-growth in two of six community shower rooms, and 3. Loud alarm noises during meal services during four of four days observed (4/27/2026, 4/28/2026, 4/29/2026, and 4/30/2026).

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide life enriching activities and assistance with activities for cognitively impaired residents residing on the secured unit of one cognitively impaired unit reviewed, failed to provide activities to one (Resident #7) of one bedridden residents, and failed to facilitate and assist one (Resident #120) of one residents with outside activities.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement and maintain an effective infection control program related to 1) cleanliness and maintenance of the laundry room, 2) educate staff on hand hygiene and personal protective equipment required for the prevention of spreading Clostridioides difficile (C. diff) after two (#41 and #91) of two residents tested positive for the highly contagious bacteria and two (#1 and #39) of two sampled residents were actively being tested for the bacteria and 3) provide Pneumococcal immunization for one (R#20) of five residents sampled for the administration of vaccinations.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure call light accessibility for one (Resident #94) of 10 residents reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure Preadmission Screen and Annual Review (PASRR) was accurate for one (Resident #81) of two residents reviewed for PASRR. Findings Include: Review of Resident #81's admission record revealed she was admitted to the facility on [DATE] with diagnoses to include anxiety, major depressive disorder, bipolar disorder, and dementia. Review of Resident #81's admission Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was 14/15, which reflected intact cognition; and acknowledged Feeling down, depressed or hopeless 7-11 days a week. Review of the psychiatry progress note dated 4/10/26 revealed . Depression: [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to develop and implement care plan problem areas related to oxygen therapy for one (Resident #11) of six sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure access to vision services for one (Resident #73) of one resident reviewed for communication and sensory problems.

Inspectors wroteBased on observations, interviews, record review, and manufacturer specification review the facility failed to maintain the settings of a low air loss mattress for one (#12) of two residents investigated for the worsening and/or development of pressure ulcers.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure one (Resident #13) received meals prior to going to dialysis out of one resident reviewed for dialysis.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure medication error rate was not greater than 5%. A total of 27 opportunities were observed with 2 errors constituting an error rate of 7.41%.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide timely laboratory services for one (Resident #130) of three residents reviewed.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure supervision was provided to residents identified as requiring enhanced monitoring (EM), one to one (1:1) supervision, and/or continuous monitoring (CM) for six residents (#1, #3, #4, #6, #22, and #24) out of six residents sampled.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the physician of abnormal laboratory (lab) values for three residents (#7, #18 and #26) out of eight residents sampled. Findings Included:During an interview on 3/10/26 at 12:58 p.m. the Director of Nursing (DON) said for abnormal laboratory test values the nursing staff are expected to notify the doctor as soon as possible and the notification should be documented in the medical records.1) A review of Resident #7's admission record showed an admission date 2/4/26 with a primary diagnosis of left ilium (pelvic) fractureA review of Resident #7's lab report results revealed on 3/7/26 reported at 5:55 p.m. a TSH (thyroid stimulating hormone) level was 26.99, reference range 0.45-5.33 uI/ml (units/milliliter). A review of Resident #7's nursing note, dated 3/9/26 at 3:32 p.m. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure the comprehensive care plan was implemented related to one to one supervision/enhanced monitoring for one resident (#24) out of ten residents sampled.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide incontinence care for one resident (#12) out of three sampled for activities of daily living.

Inspectors wroteBased on observations, interviews and record review of the facility's Shift to Shift Controlled Medication count sheets, the facility did not ensure accurate documentation of controlled substances count logs for three carts (200-A, 100A - and100-B) out of ten medication carts. On 02/03/2026 at 9:25 a.m., an observation was made of the medication cart identified as cart 200-A. A review of cart 200 -A's narcotic book showed the Shift-to-Shift Controlled Medication Count with no entry for this morning's count. Staff G, Licensed Practical Nurse (LPN) who was assigned to the 200-A medication cart stated she forgot to mark the number of total narcotic cards, but the count was correct. On 02/03/2026 at 9:59 a.m., an interview was conducted with Staff C, LPN. [...]

Inspectors wroteBased on observations, interviews, record review, and review of the facility's Plan of Correction (POC), the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee effectively implemented and monitored corrective actions to prevent recurrence of deficient practices. The facility had previously been cited under F 755 during a complaint survey conducted on 2/3/26 and developed a Plan of Correction with a completion date of 3/2/26. The review showed the facility did not fully implement or sustain the corrective actions identified in the Plan of Correction. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to accurately reconcile an anti-psychotic medication per their policy, for one resident (#5) out of three residents sampled.

Inspectors wroteBased on observations, record review and interviews the facility failed to promptly notify the physician of laboratory testing results for two (Residents #1 and #2) of two residents sampled.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to maintain a safe, clean, comfortable and homelike environment related to pest sightings in five Wings (100, 200, 300, 400, and 500) of the five facility Wings toured.

Inspectors wroteBased on interviews and record reviews the facility failed to inform the family of changes in condition for one resident (#6) of three sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one (#3) of three sampled residents was free from the abusive behavior of a staff member.

Inspectors wroteBased on record reviews and interviews, the facility failed to screen one (#4) of three sampled residents for trauma-informed care following allegations of abuse.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was labeled and dated in the walk-in refrigerator, temperature logs were completed per facility policy, and dinnerware was properly sanitized.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of one walk in refrigerator was free from ice buildup and was maintained in safe operating conditions.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for seven (Residents #38, #3, #1, #149, #151, #177,and #189) out of 44 initially sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure laboratory testing and anticoagulant medications were completed and administered per physician orders for one (Resident #182) of one resident sampled for anticoagulant use, failed to obtain orders for management of a Peripherally inserted central catheter (PICC) for one (Resident #86) of one resident sampled for the use of a PICC, failed to obtain physician orders and document the treatment of one (Resident #271) of one resident sampled for undocumented skin condition, and failed to complete dressing changes as ordered for one (Resident #162) of two residents sampled for dressing changes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey on 03/04/24 to 03/07/24 and was cited for F 812 and F908. During the revisit on 04/29/24, the facility was recited for F 812 and F908. The facility had developed a Plan of Correction with a completion date 04/06/24. The facility had not comprehensively implemented the plan of correction for the identified deficiencies.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure dignity and respect during the dining experience for four (2 unknown, #56, and #322) out of four residents requiring supervision on the 300-unit as evidence by not removing dinnerware from meal trays, not serving one (#56) out of three residents seated at the common area table together, removing two (one unknown female and #56) out of two residents from the table until their meals arrived, and standing up while assisting one resident (#273) out of one resident observed for needing dining assistance.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure one (Resident #180) of one sampled resident was free from restraints and was not evaluated for a restraint.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for one (Resident #525) of one resident to ensure a resident who entered the facility with a indwelling catheter was assessed and received appropriate physician orders, treatment, and services. Findings Included: On 03/04/2024 at 9:38 a.m., Resident #525 was observed sitting in his bed, with a cast on his right arm and a [Brand name]catheter over his left leg to a drainage bag hanging on the frame of the bed facing the door, no privacy bag present. There was cloudy yellow urine in the tubing and drainage bag. Resident # 525 stated he had the catheter as he had multiple sclerosis (MS) and a neurogenic bladder. Resident #525 stated he had a fall at home which resulted in him having a broken right arm. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure one of one garbage dumpster was maintained in a sanitary condition and free from debris.

Inspectors wroteBased on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Risk Manager, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility failed to protect the resident's right to be free from neglect by not ensuring one (#1) of 58 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility staff failed to ensure the safety of Resident #1; [...]

Inspectors wroteBased on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Risk Manager, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, facility failed to ensure one resident (#1) of 58 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility staff failed to ensure the safety of Resident #1; [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe and homelike environment related to two (500 hall and 200 hall) of two resident shower rooms observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure prompt efforts were made to resolve grievances for through to their conclusion for three residents (#1, #5, and #8) out of three residents sampled for grievances.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was complete and accurate for two residents (#1 and #3) of three sampled residents for resident record documentation.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and maintain an effective infection prevention and control program to control the spread of infection by: 1) failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for one resident (#2) of two residents sampled for transmission based precautions, 2) failing to ensure appropriate signage was posted outside of a resident room under transmission based precautions for one resident (#2) of two residents sampled for transmission based precautions, and 3) failing to ensure physician's orders for transmission based precautions were in place in a timely manner for one resident (#3) of two residents sampled for transmission based precautions.

Inspectors wroteBased on observations, interviews, and policy review the facility did not ensure residents were treated with dignity during dining related to knocking on the door or announcing oneself prior to entering the room with lunch meals on one hallway of eleven halls on one of five nursing units, during two of two dining services observations.

Inspectors wroteBased on observations, record review, and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for five (Residents #12, #37, #72, #97, #307) of 58 sampled residents, related to maintaining resident equipment in good repair for Resident #12 and providing a clean and homelike environment for Residents #37, #72, #97 and #307.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure treatment and care in accordance with professional standards of practice related to a surgical wound for one (Resident #21) of one sampled resident.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services related to storage of nebulizer equipment, consistent with professional standards of practice for one (Resident #183) of one resident investigated for respiratory therapy.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that prescribed medications were stored in a locked container for two (Residents #21 and #182) of 58 sample residents.