Valley Oaks Post Acute

Inspectors wroteBased on interview, record review, and facility policy and procedure review, the facility failed to ensure the accurate reconciliation, documentation, and accountability of controlled medications for one of two sampled residents (Resident 1). This failure resulted in the loss and potential diversion of 30 controlled -substance tablets. During a review of the facility's policy and procedure (P&P) titled, Drug Diversion Policy and Procedure, undated, the P&P indicated, controlled substance counts shall be completed at every shift change by two licensed nurses. Any medication discrepancy shall be reported immediately. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided resident care and services in accordance with professional standards of nursing practice when physician medication orders and instructions were not followed for three of six sampled residents (Residents 13, 6, and 3). These failures had the potential to result in unsafe nursing care practices which could compromise the health and safety of these residents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure identifiable information was secured and kept confidential when: one resident (Resident 51) patient identification sticker was left unattended on top of the locked medication cart. This failure had the potential to result in unauthorized access to protected health information (PHI) and a violation of the resident's right to privacy and confidentiality. During observation on 2/10/26 at 6:18 a.m. of [NAME] medication cart. One patient identification label on top of medication cart left unattended. During an interview on 2/10/26 at 7:14 a.m. with Charge Nurse. Charge nurse stated patient identification label should not be left unattended on cart. During a review of facility's Policy and Procedure (P&P) titled, HIPPAA Compliance, dated 9/30/13. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop an individualized comprehensive care plans for two of four sampled residents (Residents 9 and 40) when: Resident 9 did not have an initial care plan addressing the use of Trazodone (a medication used to treat anti depressive disorder). Resident 40 did not have a care plan in place for Sacro coccyx pressure injury. These failures had the potential to affect residents' health and safety by not providing staff with appropriate guidance to meet identified needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medications were stored in a sanitary manner and separated from non-medication and food items when: The facility failed to remove two unidentified and unlabeled medication tablets found in one of two medication carts (West Cart). 2. The facility failed to remove two open syringes from medication cart. 3. The facility failed to remove one open containers of pudding from the medication cart. 4. The facility failed to maintain original pharmacy packaging for one resident (Resident 64) when combined two syringes of Enoxaparin (a medication that treats of prevents blood clots) 40 mg (milligram)/0.4 ml (milliliter), expires on 03/2028 in same bag as four syringes of same medication expiring 8/2028. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for one resident (Resident 1) when it was documented a medication was administered when in fact the resident left the facility, and the medication was administered by an outside provider. This failure resulted in Resident 1's medication administration record (MAR) reflecting inaccurate documentation of prescribed medication.

Inspectors wroteBased on interview and record review, the facility failed to document a comprehensive nursing assessment for one of two residents sampled (Resident 1). This failure had the potential for the receiving facility not to have sufficient information necessary to develop and implement a plan of care to meet Resident 1's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) received treatment for two pressure ulcers. This failure had the potential for the pressure ulcers to become worse and delay healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments and notifications of change in conditions were completed for one of three sampled residents (Resident 1) when: 1. A change in condition (COC) was not completed for Resident 1's right eye. 2. A post fall risk assessment was not completed. 3. Family was not notified of Resident 1's COCs. 4. Interdisciplinary Team (IDT) meeting was not conducted within 72 hours of Resident 1's COCs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) received quality care when Resident 1 was admitted to the facility with a diagnosis of Type 2 Diabetes ([DM2] a chronic condition when blood sugar levels are persistently high [hyperglycemia]) and continued to have high blood glucose levels. This failure resulted in Resident 1 being transferred to the hospital and had the potential to contribute to the resident's death the following morning.

Inspectors wroteBased on observations, interviews, facility policy review, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure dishware was allowed to air dry before being stacked in 1 of 1 facility kitchen. Stacking the dishes while still wet/damp had the potential to create an environment conducive to microbial growth, which could result in foodborne illness. The failed practice had the potential to affect all 51 residents who resided in the facility and received meals from the kitchen.

Inspectors wroteBased on observations, interviews, records reviews, and facility policy review, the facility failed to ensure an evaluation for causative factors was conducted and documented after each fall to facilitate the ability to develop effective fall prevention interventions and failed to ensure accurate information about residents' falls was maintained for 2 (Resident #36 and Resident #25) of 2 sampled residents reviewed for accidents.

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to ensure the quality assessment and assurance (QAA) committee developed and implemented appropriate plans of action to correct and identify quality deficiencies related to evaluation, tracking, and documentation of falls to facilitate the ability to identify any patterns, determine causal factors, and enable the facility to ascertain whether appropriate and effective interventions were implemented for 2 (Resident #25 and Resident #36) of 2 residents reviewed for falls.

Inspectors wroteBased on observation, interview, record review, facility document review, facility policy review, and review of the Centers for Disease Prevention and Control (CDC) guidelines, the facility failed to ensure staff adhered to contact isolation precautions and donned the appropriate personal protective equipment while performing care or services in the room of a resident (Resident #26) with a known communicable disease (Clostridium difficile [C. diff]), to prevent the potential spread of C. diff infection to other residents. The failed practice was identified for 1 (Resident #26) of 1 resident reviewed for transmission-based precautions (TBP) and had the potential to affect 14 other residents who resided on the East Hall and were likely to receive care from staff assigned to Resident #26.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide residents with access to their personal funds on weekends for 1 (Resident #20) of 5 residents sampled for personal funds .

Inspectors wroteBased on record review and interview, the facility failed to submit the findings of an alleged abuse investigation to the State Survey Agency (Department) within five working days of the incident. This failure had the potential to compromise resident's health and safety, and delay necessary actions to protect residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized tool that measures health status in nursing home residents) assessment accurately reflected the residents status for one of three sampled residents (Resident 1). This failure resulted in the documentation of inaccurate assessments and had the potential for Resident 1's identified care needs to go unmet.

Inspectors wroteBased on record review and interview, the facility failed to follow their policy and procedure (P&P) to review and revise a person-centered comprehensive care plan for one of three residents (Resident 1) who exhibited aggressive behavior towards other residents. This failure resulted in Resident 1 becoming aggressive and kicking another resident (Resident 2) in the leg and had the potential to place other residents at risk for serious injury.

Inspectors wroteBased on observation, interview , and record review, the facility failed to ensure staff implemented its policy and procedure (P&P), Activity planning and Procedures for the Activity Director, (undated), for 40 of 40 sampled residents when: 1) residents did not receive a written evaluation as to their abilities to participate in activities and signed by a physician; 2) residents did not receive an individual activity treatment plan based on their individual likes and preferences; and 3) there was no documentation of individual problems, needs, and goals in any of the 40 resident's medical records. These cumulative failures have the potential to result in physical and psychosocial harm to residents and a reduction in achieving and/or maintaining their highest level of mental and physical well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling and sanitation were implemented when: 1) Two of two buckets containing sanitizing solution was not at an effective concentration to sanitize a food contact surface. 2) The ice machine was not maintained in a sanitary manner. 3) The temperature monitoring log for the refrigerator, located at the nursing station, was greater than 41 degrees Fahrenheit (F) multiple times in which the staff failed to identify and report for immediate remedy. These failures had the potential to place the residents at an increased risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post a copy of the facility's grievance procedure on the resident bulletin board as required in its policy and procedure titled, Grievances/Complaints, Filing, dated April 2017. This facility failure has the potential for: 1) all residents or resident representatives not knowing how to file a grievance/complaint and resident's issues not being heard or resolved; and 2) not properly documenting and recording resident grievances in the, Resident Grievance Complaint Log.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the activity director (AD) had the required qualifications and experience per the facility job description titled, [Name of Facility] Activity Director Job Description, (undated). This failure has the potential to result in physical and psychosocial harm to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a policy and procedure to ensure safe and sanitary storage, handling, and consumption of food items when food was stored in a designated refrigerator, adjacent to the nursing station, that could include food brought to residents by family and visitors. This failure has the potential for unsafe food storage, handling, and consumption that could place the residents at an increased risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its policies and procedures (P&P) on COVID-19 (a respiratory infection caused by the SARS-Cov 2 virus) infection prevention and control were followed when: 1) the facility did not properly screen the State/Federal survey team for COVID-19 upon entry at the facility's north wing entrance; and 2) LN4 did not follow the facility's polices and procedures (P&P), Infection Prevention and Control Measures, and Administering Medications, during medication administration to two sampled residents (Residents 36 and 41) who were on transmission-based precautions (TBP) in the facility's designated COVID-19 quarantine zone. These failures had the potential to spread COVID-19 to residents, staff and/or other visitors going in and out of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Residents 36 and 41) were provided reasonable accommodation for the use of the facility's call light system. This facility failure had the potential for the residents not to have their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Change of Condition (COC - a system for identifying, evaluating, and reporting when resident's condition changed) per their policy and procedure for one of 12 sampled residents (Resident 35) when Resident 35 fell. This facility failure had the potential for vulnerable residents to not receive appropriate care, decline in their functional mobility, and development of skin breakdown and have a delay in treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a proper and alternative means of communication for translation services for one of 12 sampled residents (Resident 16). This facility failure has the potential for Resident 16's physical and psychosocial needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate during staff medication administration was less than five percent. The facility had a cumulative medication error rate of eight percent when 2 errors of 25 opportunities for errors, were observed between two licensed nurses who administered medication, to one unsampled resident (Resident 42) and 1 of 12 sampled residents (Resident 41). The observed medication administration errors were: 1) Resident 42's medication order of Carafate Suspension (Sucralfate - medication used to treat and prevent ulcers in the stomach) was to be administered before meals and at bedtime. A licensed nurse (LN3) administered the medication after Resident 42 had eaten breakfast; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate during staff medication administration was less than five percent. The facility had a cumulative medication error rate of eight percent when 2 errors of 25 opportunities for errors, were observed between two licensed nurses who administered medication, to one unsampled resident (Resident 42) and 1 of 12 sampled residents (Resident 41). The observed medication administration errors were: 1) Resident 42's medication order of Carafate Suspension (Sucralfate - medication used to treat and prevent ulcers in the stomach) was to be administered before meals and at bedtime. A licensed nurse (LN3) administered the medication after Resident 42 had eaten breakfast; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep an unattended medication cart locked while parked at the nursing station. This facility failure has the potential for residents and/or visitors to have access to medications that could lead to adverse complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services to 1 of 12 sampled residents (Resident 38). This resulted in Resident 38 not having teeth to chew food, having to be put on a modified diet, and has the potential for weight loss and poor self-image.

Inspectors wroteBased on interview and record review, the facility failed to ensure one cook (Cook1) was competent on internal cooking temperatures for ground beef and poultry to ensure food safety. This failure placed the residents at risk of a foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu as planned when: 1. A fortified menu item was not served for 1 of 12 sampled residents (Resident 23) as directed on the meal tray card. 2. The menu for a therapeutic renal diet was not followed for 1 of 12 sampled residents (Resident 36). These failures had the potential to not meet the residents nutritional needs per the planned menu as approved by the facility's Registered Dietitian.