Valley Hi Nursing Home

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure soft and bite sized foods were cut to 1/2 (inch) x (by) 1/2 x 1/2 sizes before plating and serving. This applies to 4 of 4 residents (R36, R64, R105, and R97).

Inspectors wroteBased on interview and record review the facility failed to perform MDS-Minimum Data Set assessments every 3 months (92 days) for 3 of 7 residents (R26, R31, R61) reviewed for MDS assessments in the sample of 24.

Inspectors wroteBased on interview and record review the facility failed to accurately reflect R3 and R29's status in the MDS-Minimum Data Set for 2 of 7 residents reviewed for accurate MDS in the sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. This applies to 1 of 24 residents (R2) reviewed for activities of daily living in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an ordered treatment was in place for one of 24 residents (R42) reviewed for Quality of Care in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply an ordered medicated patch. This applies to 1 of 4 residents (R2) reviewed for medication administration in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication regime review was addressed by the physician. This applies to 1 of 5 residents (R2) reviewed for medication review in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the served portions of pureed pot roast, pureed pork stir fry, pureed carrots, and pureed soup were served at the appropriate serving size. This applies to 2 of 2 residents (R60, R78) reviewed for pureed foods in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall precautions were updated and in place for residents at risk for falls for 2 of 3 residents (R1, R3) in the sample of 3. This failure resulted in R1 falling and sustaining a head injury.

Inspectors wroteBased on interview and record review the facility failed to immediately verify a resident (R1) had not eloped from the facility after an exit door alarm sounded. The facility alos failed to supervise a resident (R1) in a manner to prevent that resident from eloping from the facility. These failures apply to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to resolve a grievance/concern verbalized by a resident's POA (power of attorney) for 1 of 3 residents (R1) reviewed for grievances in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were served food at a safe temperature. This failure resulted in R273 spilling hot soup and receiving full thickness burns on his right forearm and abdomen. The facility failed to safely transfer residents with a mechanical lift. The facility failed to ensure medications were stored in a safe manner away from a cognitively impaired resident. The facility also failed to ensure residents at risk for choking were supervised during meal times and provided thickened liquids as prescribed. This applies to 6 of 18 residents (R17, R9, R51, R52, R53 & R273) reviewed for safety and supervision in the sample of 18. The failure to ensure safe food temperatures resulting in R273 sustaining a burn due to hot foods resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure opened, multi-dose vials of medication, including inhalers and gels, were labeled with expiration dates. The facility failed to discard an expired medication. These failures apply to 5 of 5 residents (R23, R12, R41, R19, R31) reviewed for medication storage in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to screen for and offer the COVID-19 immunization to residents for 4 of 5 residents (R64, R38, R59, R65) reviewed for the COVID-19 immunization in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a non-pressure sacral wound was treated, as ordered, for 1 of 5 residents (R370) reviewed for non-pressure wounds in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a catheter drainage bag was maintained below the level of the bladder for 1 of 1 residents (R49) reviewed for catheters in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to ensure a resident took all medications during medication administration. This applies to 1 of 3 (R48) reviewed for medication administration in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure PRN (as needed) anti-anxiety (psychotropic) medications had a duration/end date. This applies to 2 of 5 (R53, R63) reviewed for unnecessary medications in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve pureed barbecue beef brisket at safe temperatures. This applies to 3 of 3 residents (R46, R28, R10) reviewed for pureed diets in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pureed barbecue beef brisket in a smooth, pudding-like consistency for residents requiring a pureed diet. This applies to 3 of 3 residents (R46, R28, R10) reviewed for pureed diets in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to evaluate a resident for Physical Therapy (PT) after receiving an order to start PT for 1 of 5 residents (R17) reviewed for rehab/therapy in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility's binding arbitration agreement was explained to a resident in a form and manner that the resident could understand for 2 of 3 residents (R274, R59) reviewed for binding arbitration agreements in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to screen for and administer influenza (flu) and pneumococcal immunizations to residents for 2 of 5 residents (R64, R19) reviewed for influenza and pneumococcal immunizations in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure resident care equipment was in safe working order. This applies to 2 of 18 residents (R24 & R37) reviewed for safe operating equipment in the sample of 18.

Inspectors wroteBased on interview, and record review the facility failed to provide mechanical lift training to facility staff using lifts for resident's requiring mechanical lifts for transfers. This applies to 1 of 1 (R48) reviewed for training requirements. On 3/19/2024 at 11:45AM, V17 Home Health Aide said she had not received any training on the Hoyer lifts from the facility. V17 said she was transferring [R48] with the assistance of V14 - Certified Nursing Assistant. V17 said the Hoyer lift started to tip and [R48] bumped her head on the lift, no bleeding or bruising noted. On 3/19/2024 at 12:27PM, V7 Licensed Practical Nurse (LPN)/ Rehab Coordinator said she does not believe [V17] received Hoyer lift training. V7 said training is offered and those people working that day receive training. V7 said the facility is responsible for Hoyer lift training. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure catheter drainage bags and tubing were not laying on the floor or bed. The facility failed to ensure expired catheter supplies were removed from use for 4 of 4 residents ( R19, R65, R69 & R141) reviewed for catheters in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the theft of $40 from a resident's wallet. This applies to 1 of 3 residents (R54) reviewed for abuse in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to report to the local health department and local law enforcement the reasonable suspicion of resident theft. This applies to 3 of 3 residents (R54, R64, & R283) reviewed for abuse in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify allegations of theft as being allegations of abuse and then failed to conduct a complete investigation of abuse. This applies to 3 of 3 residents (R54, R64, & R283) reviewed for abuse in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders by administering insulin to a resident experiencing a low blood sugar level and failed to follow facility standing orders for treating low blood sugars for 1 of 1 resident (R35) reviewed for medications.