Valley Pointe Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water temperatures were maintained within a safe range for five of eight sampled residents (Residents 1, 40, 45, 59, and 60) when two Jack-and-[NAME] bathrooms (shared bathrooms with two separate entrances from two different rooms) had faucet sink water temperatures exceeding 120 (degrees) Fahrenheit (a temperature scale used to measure how cold or hot something is). This failure placed Residents 1, 40, 45, 59, and 60 at risk for scald (type of burn caused by contact with hot liquids or steam) injuries. [...]

Inspectors wroteBased on interview and record review, the facility did not demonstrate competency in dialysis care to provide services for four (Resident 22, Resident 32, Resident 66, and Resident 3) of four dialysis-dependent (dialysis, a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys fail) residents in accordance with the facility assessment. This failure did not ensure the licensed nurses' competency and skills were met to provide safe care which could potentially result in dialysis-dependent residents receiving inappropriate care and services. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure medications were administered in accordance with physician orders for two of two sampled residents (Resident 1 and Resident 5) when licensed nursing staff administered medications, including anticoagulant (commonly known as blood thinners, are substances or medications that prevent or reduce the body's ability to form blood clots) and antiplatelet (medications that prevent blood cells called platelets from sticking together and clumping) medications, approximately 90 minutes earlier than physician-ordered administration times and subsequently documented inaccurate administration times that did not reflect the actual time of medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 47 when:1. Multiple medications with different routes of administration (a way by which a drug is taken into the body) were stored together in medication refrigerator and Medication Cart #1.2. Four pre-refilled COVID-19 (contagious respiratory illness) vaccine (medication that helps body build immunity against a disease) syringes were stored in the medication refrigerator without the original container and without labeling. These failed practices had the potential for medication identification errors, contamination, improper medication use, and administration errors. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when:The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Facial hair was not covered. 3. Meal preparation equipment was not air dried. 4. The food preparation sink did not have backflow prevention. 5. Opened food in resident refrigerator was not labeled and dated. 6. The kitchen environment was not clean or in good working order. 7. The test strips used to monitor cleaning solution levels were expired. These failures posed the risk for foodborne illnesses in a highly susceptible resident population of 45 facility residents who received food prepared in the kitchen. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure proper disposal and containment of refuse. The outdoor dumpster located near the facility was observed with its lid propped open due to an overflow of trash inside the container. Additional refuse, including dirty gloves and food waste, were scattered on the ground beneath and around the bin. The recycling area also contained overflowed cardboard boxes and other recyclables placed on the ground next to the recycling container. These deficient practices had the potential to attract rodents and insects and cross-contamination of food. During a concurrent interview and observation on 4/27/26 at 2:33 p.m., of the outdoor dumpster area with the Registered Dietitian (RD), the dumpster lid was observed propped open due to an overflow of trash inside the container, and a strong foul odor was present. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection prevention and control policies and procedures when:1. For one (Residents 45) of three sampled residents, resident's unbagged continuous positive airway pressure (CPAP, a machine that uses a mask to supply air pressure in keeping the airway open) mask and nebulizer (used to deliver medication in a fine mist over the nose and mouth) mask were left exposed to air.2. For one (Residents 59) of three sampled residents, Resident 59's unbagged nasal cannula was found on the floor.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services consistent with professional standards for one of five sampled residents (Resident 72) on oxygen (O2, a prescription drug used to treat low blood oxygen level) therapy when the facility did not follow physician orders for oxygen administration. This failure resulted in Resident 72 receiving more oxygen than ordered, which placed the resident at risk for serious harm. A review of Resident 72's admission Records, printed on 4/28/26, indicated resident was admitted to the facility on [DATE] with diagnoses that included multiple rib fractures and history of fall. A review of Resident 72's Care Plan, indicated a focus titled, Oxygen: Resident requires the use of oxygen (continuous) related to shortness of breath due to (d/t) .rib fractures. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures to one sampled resident (Resident 49) to ensure the timely acquisition, dispensing, and administration of routine medications when Resident 49's inhalation medication was not available during medication administration. This failure had the potential to result in delayed or missed medication administration and had the risks for increased exacerbation of respiratory conditions. During a record review of Resident 49's admission Record (AR) printed on 4/30/26, the AR indicated Resident 49 was admitted to the facility in February 2026 with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into brain tissue) and cognitive communication deficit (difficulty communicating because of thinking skills). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 49) received medications as ordered without an error. The facility's medication pass observation during the survey resulted in two errors out of 31 opportunities and indicated a medication error rate of 6.45 percent (%). This failure placed Resident 49 at risk for not getting the full therapeutic effect of their prescribed medications and had the potential to result in adverse health outcomes including, worsening of respiratory symptoms, increased risk for blood clot (thick, viscous, or semi-solid lump formed when blood thickens) formation and stroke (a medical emergency caused by a sudden interruption of blood flow to the brain or a ruptured blood vessel, leading to rapid brain cell death). [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in safe operating conditions when:The ice machine was not sanitized as per the manufacturer's instructions. The facility failed to follow the manufacturer's required maintenance and operational guidelines for the equipment. This failure had the potential to prevent the equipment from functioning as intended, which could have resulted in the gradual degradation of its internal components and compromised its reliability and safety. During interview and observation on 04/27/2026 at 3:05 PM, the Maintenance Supervisor (MS) was observed utilizing Clorox bleach-type solution for cleaning the ice machine. This method does not align with the manufacturer's recommendations, which specify the use of a Montauk-type descaler solution. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, comfortable and homelike environment when one of four sampled resident room (Resident 102) had dust covering the ceiling air vent, scattered areas of peeling paint on the wall, and task lighting cord was not long enough for resident to reach. This failure had the potential to compromise Resident 102's health by exacerbating (making something that is already bad even worse) the respiratory symptoms and decreasing the resident's autonomy (the capacity to decide for oneself and pursue that course of action) .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1. Resident 5's Latanoprost was stored beyond the use by date in the medication cart (Latanoprost is an eyedrop used to treat a condition in which increased pressure in the eye can lead to gradual loss of vision). 2. Six Retacrit medication vials which belonged to discharged resident 261 were found in medication room refrigerator (Retacrit is a medication used to treat a blood disorder caused by a kidney disease). 3. One opened unlabeled Lispro insulin vial was found in medication room refrigerator (Lispro insulin is a fast-acting injection medication that helps treat high blood sugar in the body). 4. Resident 11 did not have an accurate medication card label for Metoclopramide that matched the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner, when food preparation utensils and equipment were not cleaned and/or maintained in good condition. These failures placed 44 residents who received food from the kitchen at risk for food borne illnesses or illnesses related to use of contaminated utensils.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures when the specimen refrigerator (a specimen refrigerator is a specialized cooling unit used to store various biological samples collected from patients, such as urine, stool, blood, or tissue) was observed to be stored in the medication storage room. These failures had the potential to contaminate the residents' medications and for the spread of infectious disease.

Inspectors wroteBased on observation, interview, and record review, facility failed to provide meal assistance in a dignified manner to Resident 254. This failure resulted in an undignified and disrespectful treatment of Resident 254 which could potentially result in more serious negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for one of 13 sampled residents (Resident 3) who was not assessed for smoking. This deficient practice created a potential risk for burn injury to Resident 3 while smoking and placed other residents' lives in danger.

Inspectors wroteBased on observation and interview, the facility failed to provide 10 of 45 residents in resident rooms [ROOM NUMBER] with at least 80 square feet per resident. This failure had the potential to result in lack of sufficient space for the provision of care by facility staff, and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for residents and staff to move about safely and without obstruction. The State Agency recommends renewal of waiver.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to two of 20 sampled residents (Residents 148 and 23) as follows. 1 a). Resident 148, identified as a high risk for falls, was not provided with a sitter after the resident was deemed needing one-one supervision to prevent further falls. This resulted in Resident 148 sustaining another serious fall injuries (a comminuted fracture that is broken in at least two pieces caused by trauma to the right clavicle (collarbone), and a subdural hematoma (condition when a pool of blood develops between the brain and its covering, usually from head trauma). b). Resident 148 eloped on 12/7/23 and was later found in a hospital emergency department (ED). This episode of elopement was not reported by the facility to the department. 2. [...]

Inspectors wroteDuring an observation on 1/24/24 at 7:20 a.m., the entry door was open to the shared room (Room B) of Resident 28 and Resident 149. On the wall adjacent to Room B was a posted sign which indicated, Stop Red Room. During an observation on 1/24/24 at 7:50 a.m., Certified Nursing Assistant 5 (CNA 5), Registered Nurse 2 (RN 2) and Certified Nursing Assistant 3 (CNA 3) were passing the breakfast meal trays from the meal tray delivery cart to resident rooms. RN 2, CNA 3, and CNA 5 entered the Room B without donning PPE. RN 2, CNA 3, and CNA 5 exited Room B and did not perform hand hygiene. During an interview on 1/24/24 at 7:53 a.m., with Infection Preventionist/Director of Staff Development (IP/DSD), IP/DSD stated the residents in Room B (Resident 28 and Resident 149) both had COVID. IP/DSD stated the door to their shared room should be kept closed at all times. [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain the facility's ventilation system in a safe operating condition when the heating, vacuum, air conditioning (HVAC) in the broiler room did not have the required MERV 13 filtration recommended for healthcare settings during a COVID-19 outbreak. (MERV filters reduces up to 75% of large airborne particles including: dust and lint, dust mite debris, pollen, per dander, mold spores, bacteria and virus carriers). This failure had the potential to spread airborne infections during COVID-19 outbreak.

Inspectors wroteBased on interview and record review, the facility failed to facilitate Advance Directives (a legal document that provide instructions for medical care that go into effect if you cannot communicate your own wishes) status, including the right to accept or refuse medical/surgical treatment for five out of five residents upon admission. These failures resulted in Residents 26, 32, 94, 192, and 193 or their responsible party (RP) not being aware of their right to participate in their medical and surgical care.

Inspectors wroteBased on interview and record review, the facility failed to complete a baseline care plan within 48 hours, and provide three (Residents 18, 93, and 94) of 20 sampled residents and their representatives with a summary of the baseline care plan. This failure did not ensure the minimum healthcare information to plan care for each resident upon admission and provide the baseline care plan summary indicating residents and representatives were informed.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months when; - Five of five Certified Nursing Assistants' (CNAs) annual performance evaluations were not completed. - Three of five licensed nursing staff did not receive ongoing in-service training for the use of personal protective equipment (PPE) and isolation precautions during a COVID-19 outbreak. This failure had the potential for the spread of infection due to unknowledgeable staff about managing and caring for residents during a COVID 19 outbreak.

Inspectors wroteBased on observation, interview and record review, the facility failed to label medications and properly dispose of expired medications for two of 20 sampled residents (Resident 17 and Resident 12), for medication cart one: 1. Resident 17's three open inhalers (devise used for inhaling medicine into the lungs) were found with no open date labels. 2. Resident 12's one bottle of acetaminophen (pain and fever medication) caplets was expired. This failure could potentially expose residents to the expired medications loss of potency and efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were served palatable food when food was served at a low temperature. This failure had the potential for 48 of 48 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Temperature of the food was not palatable.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. Food was opened, unlabeled and undated. 2. The blender container was cloudy and dirty. 3. The bottom shelf of two-door freezer had crusted food and ice buildup. 4. Two dry food storage bins containing food were dirty, unlabeled, undated. 5. Cutting boards were dirty and ready for use. These failures put the facility at increased risk for food contamination and food borne illness for 48 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one visually impaired resident (Resident 30) of two sampled residents assistance with eating when the Certified Nursing Assistant (CNA 4) did not assist Resident 30 with meal tray set-up and food positioning on the plate. This failure caused Resident 3 confusion and challenges with eating.

Inspectors wroteBased on observation, interview, and record review, the facility had three resident rooms (Room numbers 19, 20, 21), and total of 12 licensed beds that were occupied by 12 residents, that provided less than 80 square feet (sq. ft.) per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings.