Valle Vista Rehabilitation and Nursing LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to evaluate, monitor, and manage a chronic scalp lesion/wound despite changes in the wound condition, including documented drainage; and failed to ensure timely wound management prior to and following the identification of a maggot infestation1 for 1 (#3) of 7 sampled residents. This deficient practice resulted in a decline of the resident's scalp lesion/wound condition and the development of maggot infestation1 requiring additional wound management and evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were identified and initiated, including ensuring appropriate signage was posted and personal protective equipment (PPE) was readily accessible at the point of care for 4 (#s 1, 2, 3, and 7) of 7 sampled residents who either had wounds or an indwelling foley catheter; and the facility failed to ensure hand hygiene was completed in accordance with the Centers of Disease Control and Prevention (CDC) recommendations during the distribution of clean linen for 3 (#s 5, 6, and 7) of 7 sampled residents. These deficient practices had the potential to increase the transmission of infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a significant change in condition related to a chronic scalp lesion/wound, including new onset of drainage, for 1 (#3) of 7 sampled residents. This deficient practice resulted in the physician not being provided with timely information about a change in the resident's condition necessary to evaluate the need for additional assessment, treatment, or intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive wound assessment, monitoring, and documentation of a chronic scalp lesion/wound in accordance with accepted standards of nursing practice, including complete documentation of wound characteristics including size, shape, color, and drainage for 1 (#3) of 7 sampled residents. This deficient practice limited the ability to accurately monitor and evaluate changes in the resident's chronic scalp lesion/wound, identify changes in lesion/wound status, and determine when additional clinical evaluation or intervention was required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician supervision and ongoing clinical oversight following notification of a significant change in condition involving a maggot-infested scalp wound for 1 (#3) of 7 sampled residents. There was no documented physician assessment or reassessment of the resident's condition or additional clinical guidance to address the significant change in condition while the resident awaited outpatient surgical evaluation.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records by failing to ensure the resident's medical record accurately reflected the presence, characteristics, and changes in a scalp lesion/wound for 1 (#3) of 7 sampled residents. This deficient practice resulted in an incomplete medical record that did not accurately reflect the resident's condition or provide a complete picture of the wound status, or care provided. Review of resident #3's weekly skin assessments dated 6/2/25- 6/29/25 and 11/2/25-11/16/25, showed no documentation of the resident's chronic scalp lesion/wound. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff follow safe food labeling and storage processes in accordance with standards for food service safety and failed to maintain sanitary conditions, including employee hygiene. These deficient practices affected all residents receiving food services from the facility's kitchen and dietary staff, and the deficient practices would continue if not addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and maintain a comprehensive care plan, which included the presence of a resident's hearing aids and the need for staff to assist the resident with putting the hearing aids in his ears, for 1 (#6) of 18 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised to accurately reflect individual resident-centered care needs for 3 (#s 4, 18, and 61) of 18 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the needed assistance with completing Activities of Daily Living (ADL's) for 1 (#6) of 18 sampled residents. The deficient practice resulted in a resident not wearing his hearing aids or dentures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with necessary respiratory care and services as per physician orders and failed to ensure a portable oxygen tank was replaced when the metered volume indicated empty for 2 (#s 36 and 54) of 19 sampled and supplemental residents for oxygen therapy. This deficient practice increased the risk of negative outcomes stemming from respiratory complications due to a lack of provision of oxygen.

Inspectors wroteBased on the interview and record review, the facility and staff failed to provide the necessary behavioral health services and oversight for a resident who displayed disruptive yelling, refusals of care, and verbal abuse toward staff regularly, and failed to document the resident's responsible party's refusal of behavioral health services. The medical record did not include evidence to show the facility consistently attempted to identify, trend, implement, monitor, or modify behavioral interventions consistently as the behaviors continued without change, to assist the resident with maintaining or improving her mental health and well-being, for 1 (#61) of 18 sampled residents. Due to these failures, the resident continued her disruptive yelling and refusals of care.

Inspectors wroteBased on interview and record review, the facility failed to provide a quadriplegic resident with a wheelchair after discharging and transferring him to an Adult Services Residential Program facility on the East coast and failed to document the transfer discharge of the resident in the medical record, for 1 (#2) of 4 sampled residents. This deficient practice resulted in a resident not having his main mode of locomotion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate infection prevention and control program was maintained, to include appropriate cleaning of facility equipment, and an annual review of all policies and procedures including the facility's water management system and Legionella surveillance. This deficient practice increased the likelihood of residents acquiring a healthcare-associated communicable disease or infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records, including medical provider visit notes, for 4 (#s 2, 17, 23, and 32); and failed to ensure a resident's Provider Orders for Life-Sustaining Treatment (POLST) was signed by a medical provider for 1 (#33) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure consent for the use of psychotropic medications was obtained prior to starting a psychotropic medication for 2 (#s 33 and 48) of 18 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days, unless the rationale for continuing the medication was documented by a medical provider, for 2 (#s 33 and 48) of 18 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (#46) of 18 sampled and supplemental residents. This deficient practice increased the risk of allowing resident #46's further potential misappropriation of property when allegations were not reported and investigated with facility oversight.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and or the resident's representative, in writing, of the reason for transfer when transferring a resident to the hospital, for 1 (#23) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan based on resident activity preferences and physical abilities, for 1 (#2) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with group and individual activities to meet the resident's interests, and support their physical, mental, and psychosocial well-being for 1 (#2) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary and clean condition. This had the potential to effect all residents in the facility who consumed food or services from the kitchen.

Inspectors wroteBased on observation and interviews, the facility failed to have a certified person to serve as the director of food and nutrition services. This practice had the potential to affect all residents who receive food from the kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure: food was stored and prepared in a clean kitchen; staff wore beard nets and hair nets appropriately; and dated and labeled open food items. These practices had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to remove and dispose of expired medications and medical supplies in one medication room and one treatment room. These failures increased the risk of expired medications and medical supplies being used for any resident at the facility.

Inspectors wroteBased on observations and interviews, the facility failed to provide palatable food at an appetizing temperature for 3, (#s 31, 38, and 200) of 23 sampled residents.