Valle Verde Health Facility

Inspectors wroteBased on interview and record review, the facility failed to prevent the development of an unstageable (a severe wound where the true depth and extent of tissue damage cannot be determined because the wound bed is completely obscured by dead tissue) pressure ulcer (localized damage to the skin and underlying soft tissue) in one of three sampled residents (Resident 1). Resident 1 was admitted to the facility with a left ankle-foot orthosis boot (AFO - a medical brace designed to support the ankle) status post-surgery and was found with an unstageable pressure ulcer on the left foot approximately 6 weeks later. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the POLST (Physician Orders for Life-Sustaining Treatment -a medical document that translates treatment preferences into actionable medical orders) was signed by the Responsible Party (RP- one who has authority to make healthcare decisions) for one of 4 sampled residents (Resident 14). This failure had the potential to result in Resident 14's wishes regarding medical treatment not being followed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Develop a care plan and interventions for hearing impairment for one of two sampled residents (Resident 8). This failure had the potential for Resident 8's hearing impairment to worsen and thus impact the resident's quality of life.2. Implement care plan interventions for Resident 11 related to access to call light and repositioning in bed. This failure had the potential for Resident 11 not to receive the necessary care needed. 1. During a record review of Resident 8's comprehensive assessment, dated 12/04/25, this indicated Resident 8 was assessed to have hearing impairment. During an observation on 01/07/26 at10:55 a.m. Resident 8 was in the common area near the activity room reading a newspaper with no hearing aids. When greeted, Resident 8 just stared at this surveyor. During an interview on 01/08/26 at 10: [...]

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 1Based on observation, interview and record review, the facility failed to follow a mechanically altered diet order for one unsampled resident (Resident 53), who had dysphagia (difficulty swallowing), when staff served Resident 53 coffee without thickener. This failure had the potential to cause swallowing discomfort and/or aspiration (the accidental entry of a fluid or food into the airway or lungs) for Resident 53. During a review of Resident 53's clinical record, it indicated that Resident 53 was admitted to the facility on [DATE] with diagnoses that included Bell's Palsy. During an observation on 1/6/26 at 12:18 p.m. in the resident dining room, Resident 53 was served a meal tray by staff. As Resident 53 started eating without assistance, another staff member brought Resident 53 a cup of coffee, from which Resident 53 sipped. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure:1. The Infection Prevention Control and Program (IPCP) standards and policies were reviewed at least annually. This failure had the potential for the facility to implement outdated infection control standards, policies, and protocols that can lead to an ineffective infection control program2. Staff followed manufacturer's instructions on cleaning and disinfecting a blood sugar monitor machine (glucometer). This failure had the potential for cross contamination of blood transmitted infections. During an interview on 01/08/26 at 11:30 a.m. with Infection Preventionist (IP), the IP stated the IPCP policies and procedures are online and that the Interdisciplinary Team (IDT) was responsible for reviewing the IPCP Policies and Procedures (P&P). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a patient care equipment, a glucometer (a device used for measuring the concentration of glucose in the blood for diabetics), was maintained in a safe operating condition. This failure had the potential to result in false blood sugar readings, compromising the health and well-being of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when the Director of Food and Nutrition Services (referred to as Director of Dining Services (DDS)), albeit was a full time (FT) position, DDS was responsible for not only the main kitchen that provided foodservice for the residents residing in the Health Center (skilled nursing facility), but also responsible for two other foodservice operations located on the Continuing Care Retirement Community (CCRC) campus, community Meals on Wheels, and providing food for another contracted small health facility. DDS failed to demonstrate appropriate skill set related to sufficient managerial monitoring and guidance related to: 1a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service when: 1. TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not consistently and accurately cooled down to ensure food safety. 2. The ice machine, located in a pantry near a nursing station, utilized for residents was not maintained in a sanitary condition. 3. There were unsanitary conditions in the main kitchen related to: 3a. Kitchen floors with build -up of dried food debris. 3b. Floor drains with build- up of dried food debris. 3c. Clean equipment stored on unclean shelves. 4. There was a container of cooked pasta in the walk-in refrigerator in the main kitchen that was not dated. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Emergency Drug Supply Kit (E-kit) was stocked accurately according to the table of contents. This failure had the potential for residents not to receive necessary medications in case of emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Expired items in the medication storage room, medication cart, and treatment cart were discarded and not readily available for staff use. 2. A work order was done when the temperature of the medication refrigerator was below acceptable range. These failures had the potential for residents to receive expired and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu for the therapeutic Mechanical [Mech] Soft Chopped (Level 6) [Level 6 - Soft & Bite-Sized (SB6)] diet (SB6 diet; food may be used when not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow) was developed and prepared in accordance with established national guidelines, IDDSI (International Dysphagia [difficulty swallowing] Diet Standardization Initiative), when the facility's menu modified the Level 6/SB 6 framework by incorporating unsafe foods based on an out-of-date Mech Soft Chopped diet from an obsolete National Dysphagia Diet (NDD). There were seven residents residing at the facility with a Mech [mechanical] Soft diet order that were provided Mech Soft Chopped (Level 6) menus as follows: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff accurately documented pain assessment and management based on Resident 1's care plan after a surgical procedure. This failure had the potential for Resident 1 to have extended and unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement it's policy and procedure, on Handling Controlled Substance, ( prescribed , monitored, controlled narcotics) during discharge of one of two residents (Resident 1). Resident 1 was discharged with the medication Norco, which the resident found to be missing, from his discharged paper works and belongings . Resident then informed and notified the facility . This failure had the potential for drug diversion ( medication used by others aside from the patient ), placing the resident at risk for unaddressed pain with no relief.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident 1 was wearing a gait belt (a device that helps prevent falls) at time of fall, during Resident 1's initial occupational therapy evaluation. This facility failure had the potential to create an unsafe environment for Resident 1.

Inspectors wroteBased on record review and interview, the facility failed to demonstrate it implemented individualized care planned interventions for monitoring and recording pain characteristics, for two of two sampled Residents (Resident 1 and Resident 2). This facility failure had the potential for nursing staff to inadequately capture and report to the full extent, Resident 1 and Resident 2's self-reported pain.

Inspectors wroteBased on record review and interview, the facility failed to properly secure 60 oxycodone tablets (a Schedule II drug used to treat moderate to severe pain with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) upon delivery from the pharmacy. This facility failure resulted in the facility not being able to account for where the 60 oxycodone tablets went and had the potential to negatively impact Resident 1's pain management treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a follow up/new Preadmission Screening and Resident Review (PASRR -mental disability assessment ) for Level 1 was done for one of 26 residents (Resident 3). This failure had the potential to result in Resident 3 not being adequately assessed and followed for mental health screening post admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive person-centered care plans were developed and implemented for three out of 26 sampled residents (Residents 35, 16, and 198) when: 1. Interventions for Resident 35 who had depression (a common and serious medical illness that negatively affects how you feel, the way you think, and how you act, causes feelings of sadness and/or loss of interest in activities you once enjoyed) were not followed and implemented. 2. Resident 16's care plan interventions for depression were not followed. 3. No care plan was developed for Resident 198, who was on contact precautions (everyone coming into a patient's room is asked to wear a gown and gloves prior to patient contact). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were no expired medications. This failure had the potential to result in residents receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) on food storage, sanitation of food-contact surfaces when: 1. a) Unlabeled foods were found in dry storage b) Expired food found in walk-in refrigerator 2. Dietary staff failed to demonstrate the correct procedure in testing the concentration level of the sanitizer solution used to sanitize food- contact surfaces. These failures had the potential for expired food to be served to residents and food prepared on unsanitized surfaces, which could contribute to serious food-borne illnesses.

Inspectors wroteBased on interview, and record review, the facility failed to ensure for two out of 26 sampled residents (Resident 23 and 32): 1. Resident 23's care plan on depression was revised and updated to reflect medication discontinuance when the use of the antidepressant medication (Remeron /Mirtazapine-use to treat feelings of sadness, loss of interest in activities and ADLS, ) was discontinued. This failure had the risk of inaccurate information regarding the use of Remeron on the resident. 2. Resident 23's care plan on weight loss was revised and updated when the resident gained weight. This failure placed Resident 23 at risk for wrong body weight calculation which can affect overall nutritional needs. 3. Resident 23's Restorative Nursing Assistant (RNA) exercises were documented as rendered, not rendered, and the reason not rendered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention and control practices were met when: 1) A Certified Nursing Assistant (CNA 1) was observed without an isolation gown on as personal protective equipment (PPE- disposable gowns, gloves, eye wear, shoe wear mask usage to prevent spread of infection), while taking vital signs on a resident (Resident 198), who was on contact precautions. 2) A housekeeping staff (HS 1) was observed collecting trash bags without gloves on. These failures had the potential for the spread of infection among residents, staff, and visitors.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a safe water delivery when water delivery logs on Legionella (bacteria that can cause a serious type of pneumonia [lung infection]) testing was with missing/incomplete documentation. This failure placed the facility's water delivery at risk for potential spread of Legionella.