Valley of the Moon Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food according to professional standards for food safety for a facility census of 27 residents when:A large dented can was stored in the ready for use dry storage area,Expired food items were stored in the ready for use dry storage area,An opened food package was stored without any labeling in the ready for use dry storage area, and;Scratched and peeling plastic cutting boards were in use in the food preparation area. These failures created the potential for food contamination and food borne illness for a vulnerable resident population. Cross reference F908. 1. During a concurrent observation and interview on 7/13/26 at 9:15 a.m. with the Dietary Manager (DM), a large dented can of pinto beans was found in the ready for use area. The DM stated the can should have been removed from stock.2. [...]

Inspectors wroteF689 - Free of Accident Hazards/Supervision/DevicesBased on interview and record review, the facility failed to ensure a timely post-fall risk evaluation assessment was completed following a resident fall, for one of three sampled residents, (Resident 32), reviewed for falls. This failure resulted in a missed opportunity to identify and address additional fall risk factors before Resident 32 experienced a second fall in the facility and placed him at an increased risk for potential injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one (Resident 1) of five sampled resident's right to be free from physical abuse when Resident 1 was struck by Resident 2 during an altercation that occurred on 3/06/26. This failure resulted in Resident 1's suffering bruising and skin tears to the face and arms. Resident 1 also experienced lasting anxiety following the facility failure. A review of Resident 's admission Record (facility demographic) indicated he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (oxygen and nutrients to part of the brain is blocked causing brain tissue death) with hemiplegia and hemiparesis (hemiparesis indicates weakness on one side of the body; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident right to know about, and had access to, the contact information for the Ombudsman (State Patient/Resident advocacy services) and California Department of Public Health (CDPH) and Federal and State Survey results. This failure had the potential for not allowing Residents or their family members to exercise their right to know contact advocates about their concerns regarding the care they received in the facility and how to view the results of the facility surveys and the plans of correction (A document from the facility that would state how to correct any deficiencies or findings, and to keep them from happening again.) prepared by the facility in response to a complaint investigation or recertification survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents knew about, and had access to, the contact information for the Ombudsman (State Patient/Resident advocate services) and California Department of Public Health (CDPH) and Federal and State Survey results. This had the potential for not allowing Residents or their family members to exercise their right to know contact advocates about their concerns regarding the care they received in the facility and how to view the results of the facility surveys and the plans of correction.

Inspectors wroteBased on observation, interview, and clinical record review, the facility failed to maintain a portable oxygen tank inventory and properly anticipate emergent respiratory care equipment needs for six Sampled Residents (Resident 4, Resident 2, Resident 1, Resident 13, Resident 80, Resident 6), and 2 Unsampled Resident (Resident 5, Resident 9) who received oxygen therapy. The facility's inability to ensure Resident's daily and emergent oxygen needs had the potential for Respiratory Distress (shortness of breath, difficulty breathing, and possible respiratory failure), Hypoxemia (oxygen deprivation) and potential for death, during a facility evacuation that required transport of residents to county shelters or private homes.

Inspectors wroteBased on interview and record review, the facility: 1) Failed to ensure Registered Nurses (RNs) had accurate, verified competencies (verification of essential job functions; skills/ability required to perform safe nursing care) in their employee files when 2 of 2 sampled Registered Nurses (RN B and RN C) did not have documented, complete PICC line (peripherally inserted central catheter) competencies per facility policy, and 2) Failed to ensure Licensed Vocational Nurse L (LVN L) had accurate competencies in his employee file when LVN L's employee file indicated he had PICC line competencies, but LVN's are not legally nor professionally qualified to care for PICC lines. These deficiencies caused potential for unsafe nursing practice and potentially placed PICC residents at risk of harm. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the safety of one sampled resident (Sampled Resident 1), when medication that was ordered to be administered on an empty stomach was administered at the same time as two medication that were ordered to be administered with food. This medication administration was the result of not following the physician's order and had the potential to result in medication not being absorbed properly and the risk of Sampled Resident 1 to experience side effects that included gastric upset, nausea and gastric reflux.

Inspectors wroteBased on interviews, and record review, the facility failed to provide the services of a Director of Nursing (DON) on a full time basis for the last thee months. This failure prevented the oversight of a professional Registered Nurse (RN) in the management and direction of all aspects of the nursing services department that could adversely impact the care and treatment of residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not create a care plan for one of two residents (Resident 11) who was on supplemental oxygen (O2) for 7 months. This failure could result to oxygen toxicity or oxygen poisoning (lung damage that happens from breathing in too much extra [supplemental] oxygen), which can cause coughing, trouble breathing, and in severe cases it could potentially cause death.

Inspectors wroteBased on observations and a review of records, it was determined that the facility failed to meet the pharmaceutical needs of its residents by not having proper procedures in place to ensure the accurate administration of all drugs. Specifically, during the administration of an insulin injection to Resident 25, it was observed that the injection site was not rotated, and the same site was used multiple times by several different nurses. This could potentially lead to an adverse reaction such as lipodystrophy (a disorder that affects how the body accumulates and stores fat).

Inspectors wroteBased on interviews and record reviews, it was discovered that the facility pharmacist failed to report irregularities, and the facility itself did not take appropriate action in response to these irregularities. The facility pharmacist failed to identify the lack of insulin site rotation for Resident 25, which resulted in the resident at risk for lipodystrophy due to repeated injection at the same site. Lipodystrophy is a disorder that affects how the body accumulates and stores fat.

Inspectors wroteBased on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-nine opportunities, resulting in an error rate of 10%.