Valley Skilled Nursing Center

Inspectors wroteBased on interview and record review the facility failed to timely review and revise residents' comprehensive, person centered care plans after significant changes in condition and or behavior following a resident to resident aggression on 02/20/2026 and 02/21/2026 when: Three of four sampled residents ((Res) 1, Res 3, and Res 4), did not have care plan updates documented in accordance with the facility policy. 2. Two of four sampled residents (Res 1 and Res 2), had no interdisciplinary team (IDT - a collaborative group of professionals including nurses, doctors, therapists, social workers, and dietitians who meet regularly to plan and manage a resident's care) documentation after the significant incident on 2/20/26. 3. One of four sampled residents (Res 2), had lack of documented follow up on room change and safety measures after being followed by social services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered with adequate clinical indication and clear parameters for one of four sampled residents (Resident (Res) 1), when Res 1 had two active as needed medication orders for the same medication with different dosages and the same administration criteria, which required nurses to select the dose based on their personal judgment rather than physician directed parameters. This failure had the potential to result in over medication or undermedication of Res 1 and placed Res 1, an already vulnerable patient in a nursing home at risk of receiving an unnecessary medication dose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes for three of three sampled residents (Resident 1, 2, and 3), when:1. Resident 1 had an unwitnessed fall on [DATE] and there was no care plan following a left hip fracture. This failure had the potential to result in delayed detection of post-operative complications such as pain, infection and immobility to Resident 1's left hip following surgery.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1) had the right to retain and use personal possessions when Resident 1 reported a missing pair of shoes and a hinged knee brace on 5/23/25 and staff did not follow facility policy to investigate and offer to replace or reimburse the missing items. This failure resulted in the loss of Resident 1 ' s pair of shoes and hinged knee brace without being replaced or reimbursed for the value of the items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and secure protected health information (PHI) for residents and private information for staff when two of seven sheds (a simple roofed structure used as storage space) were broken into on 4/29/25 and was not secured until 5/6/25. This failure had the potential to result in loss, destruction, or unauthorized use of resident PHI and staff private information.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered to meet the needs of one of five sampled residents (Resident 1) when nursing staff did not administer lorazepam (medication used to treat anxiety [mental condition which causes intense and persistent worry]) at the specified time frame according to the physician's order. This failure resulted in Resident 1 to receive his medication earlier than the prescribed time and had the potential to cause respiratory depression (characterized by slow and ineffective breathing), drowsiness (tiredness), change in consciousness (how alert and awake someone is), dry mouth, loss of appetite, memory impairment, trouble sleeping, abnormal movements of the body, constipation, and weakness.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for one of five sampled residents (Resident 1) when Resident 1's dose of lorazepam (medication used to treat anxiety [mental condition which causes intense and persistent worry])was not documented in the Medication Administration Record (MAR) on [DATE] and the complete record of the medication error was not documented in an incident report and Resident 1's clinical record. This failure had the potential to affect the delivery of care and services to Resident 1 and the potential to cause errors in medical treatment and plan of care.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin in accordance with the facility's policy and procedure (P&P) and state regulations, for one of five sampled residents (Resident 1), when Resident 1 had a lump to the right shoulder, lump to the right side of the chest with bruising due to an unknown cause and it was not reported to the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helping shape positive health outcomes for individuals, families and communities) and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within 2 hours as required by law. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled residents (Resident 1) when Resident 1 had a newly developed lump to the right shoulder and a lump to the right side of the chest with bruising and the care plan did not include thorough and individualized objectives, timeframes, goals, and interventions. This failure placed Resident 1 at risk for complications and delayed healing to her right shoulder and chest.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to administer oxygen according to physician orders for 3 (Residents #6, #24, and #111) of 4 residents reviewed for respiratory therapy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBPs) were provided for 2 (Resident #111 and Resident #24) of 7 residents reviewed for transmission based precautions and failed to ensure staff followed infection control practices observed during medication administration for 1 (Resident #46) of 6 residents during medication administration and 1 (Resident #111) of 1 resident during wound care.

Inspectors wroteBased on interview and facility document and policy review, the facility failed to protect Resident #44's right to be free from physical abuse perpetrated by another resident (Resident #259). This deficient practice affected 1 (Resident #44) of 2 sampled residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a diagnosed serious mental illness for 1 (Resident #35) of 1 sampled resident reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #35's initial PASARR reflected that the resident had a diagnosis of depression.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure staff assisted a dependent resident with activities of daily living (ADLs) for 1 (Resident #7) of 5 sampled residents reviewed for ADLs. Specifically, the facility failed to provide nail care for Resident #7.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide indwelling urinary catheter care per the facility's policy and accepted infection control standards and failed to maintain an indwelling urinary catheter bag below the level of the bladder for 1 (Resident #111) of 3 residents reviewed with an indwelling urinary catheter.

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to provide food that accommodated resident allergies and preferences for 2 (Resident #257 and Resident #41) of 3 residents sampled for food.

Inspectors wroteBased on interview and record review, the facility failed to follow their policies and procedures (P&P) titled, Psychotropic Medication Use,regarding the safe and appropriate prescribing and administering of psychotropic (used to treat psychosis- conditions that affect the mind, where there has been some loss of contact with reality) medication for one of five sampled residents (Resident 1) when Divalproex sodium (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and mental disorders and to prevent migraine headaches) was prescribed and administered prior to determining the appropriate indication for use. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for two of three sampled residents (Resident 1 and Resident 2), when: 1. Resident 1 had an unwitnessed fall on 7/24/24 and facility staff did not complete a change of condition (COC) assessment (used to describe situation, background, assessment of resident and physician recommendations). 2. Resident 2 had a change in urine patterns on 7/28/24, blood in urine on 7/30/24 and the facility did not complete a COC for both instances for Resident 2. These failures resulted in incomplete documentation for Resident 1 and Resident 2 putting Resident 1 at risk for falls and Resident 2 at risk for delay in care when there was no documentation of change in condition to inform other facility staff of changes in resident care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan per facility ' s policy and procedure titled Care Planning-Interdisciplinary Team for one of three sampled residents (Resident 1), when Resident 1 sustained a fracture (broken bone) of left arm on 7/24/24 and there was no care plan created for Resident 1 ' s care of the fractured right arm. This failure had the potential for harm when the facility staff did not create a care plan with interventions to monitor Resident 1 ' s fractured right arm with bandage that could have led to skin breakdown, pain, and acute compartment syndrome (bandage or cast placed on injured arm or leg too tightly) causing swelling, numbness, weakness, difficulty moving the affected body part.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurses (LVN) followed professional standards of practice for one of three sampled residents (Resident 2), when on 9/30/23 at 6:30 a.m., Resident 2's blood glucose (sugar) level was of 55 mg/dl [milligrams per deciliter [a unit of measurement]) and LVN did not communicate the result to Resident 2's physician and did not recheck Resident 2's blood glucose within 15 minutes as per the facility's Hypoglycemia (low blood glucose) policy. This failure increased the potential for Resident 2 to experience complications such as confusion, coma (a state of deep unconsciousness that lasts for a prolonged or indefinite period), headache and restlessness.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an effective infection control and prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections when staff did not disinfect equipment with an agent that would kill Clostridium difficile (C. diff -bacterial infection that causes life threatening diarrhea) bacteria. These failures had the potential to increase the risk of transmission of C. diff infection to all residents and staff of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There was no air gap for Prep sink and dishwasher machine. 2. Torn gaskets found on both Reach-in refrigerator's doors. 3. Dust found on these areas: a) Hanger for pot, pans and utensils. b) Under Food Prep stainless steel table. c) Wall in storeroom d) Four storage shelves in storeroom e) Storeroom's doorway. f) Ventilator fans in Reach-in refrigerator. g) Walk in refrigerator insulation black pipe. h) Under stainless steel table for beverage area. i) Stainless shelves for spices. 4. Storeroom's floor found food particles; walk in refrigerator's floor had rough surface and chipped paint; floor under oven had black grime and floor in dish washing area had black grime. 5. Five serving bowls did not had smooth surface. 6. [...]

Inspectors wroteBased on interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for one of 12 sampled residents (Resident 1) when Resident 1's psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) care plan was not individualized for each specific medication. This failure placed Resident 1 at risk for complications due to care needs not being planned by licensed nurses and the interdisciplinary team to determine if interventions needed to be added, changed or completed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the services provided met professional standards of practice for two of six sampled residents (Residents 3, and Resident 94) when: 1. Licensed Vocational Nurse (LVN) 1 did not take a blood pressure (the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure) reading for Resident 94 with blood pressure (BP) medication administration on 7/26/23 at 9 a.m. before administering Lisinopril (medication used to treat high blood pressure). This failure had the potential to result in an unwanted decrease in Resident 94's BP which could lead to lethargy, loss of consciousness and/or death. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form to meet individual needs for 12 of 12 sampled residents (Resident 3, 8, 10, 11, 12, 15, 16, 28, 30, 37, 38, and 241) when: 1. Residents 3, 8, 10, 11, 15, 16, 28, 30, 37, 38, and 241 did not receive Mechanical Soft diet (is a diet that contain food that is chopped into small pieces for residents who have limited chewing and swallowing ability) as indicated on physician's orders and received a regular texture dessert for lunch on 7/26/2023. 2. Resident 12 had physician order for Pureed diet (a diet with food texture of smooth like pudding or mashed potatoes that requires no chewing) but received scalloped potatoes which contained chunks of potatoes for lunch on 7/26/2023. These failures placed Residents 3, 8, 10, 11, 12, 15, 16, 28, 30, 37, 38, and 241 on choking hazard.

Inspectors wroteThe facility did not give written notification residents and/or rps about transfer to acute hospital. Resident #3 Hospitalization 07/26/23 10:43 AM recently hospitalized , not sure why. RES admitted for COPD exacerbation, hematuria, and encephalopathy. 07/27/23 10:22 AM [NAME], RN (RR) COPD exacerbation, hematuria and encephalopathy; res was on oxygen-94% NC (I)she was no 2L but not documented. RES is her own RP so nobody was notified just the NP. OMB notification of transfer was not seen in the chart. 07/27/23 10:32 AM [NAME]-only sends the OMB notification when the res discharges from ; for hospitalizations she sends them a list at the end of the month; for the discharges she gives a copy to res/rp and send it to OMB. 07/27/23 11:41 AM [NAME], DON; when a res is transferred there is a form when res gets d/c or transfer filled out and provided to RP/RES. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services for one of 25 residents (Resident 93), when the facility did not obtain medications for Resident 93 after admission to the facility on 7/25/23, and Resident 93 did not receive medications per physician's orders. This resulted in Resident 93 not receiving his medications on 7/25/223 to treat his medical conditions, and place Resident 93 at harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs were labeled in accordance with currently accepted professional standards of practice for five of six sampled residents (Resident 191, Resident 3, Resident 6, Resident 1, and Resident 34) when: 1. Resident 191 had one eye drops bottle stored in the medication cart in Hallway 3 without a resident identifier. 2. Inhalers (a device used to give medications in the form of a spray that is breathed in through the mouth) for Resident 3, Resident 6, Resident 18, and Resident 34 were stored in the medication cart in Hallway 3 without residents' identifiers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage under sanitary conditions for one of two dumpsters when trash was found on the ground around the dumpster. This failure had the potential to attract rodents, insects, and flies and could spread infection which placed the residents at risk for foodborne illness.

Inspectors wroteBased on observation during the survey period of 7/25/23 to 7/28/23, the facility failed to provide the minimum of at least 80 square feet per resident in 18 out of 34 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19). This failure had the potential for residents in Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19 to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staffing information was posted daily at the beginning of each shift for two out of four days (4/13/22 and 4/15/22). This failure resulted in facility staffing information not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The three compartment sinks (three sinks used for washing dishes, one for washing, one for rinsing and one for sanitizing dishes) and a food preparation sink did not have an air gap. 2. The handwashing sink in dish room did not have soap and one Dietary Aide (DA) failed to properly wash hands after handling soiled items; 3. There were multiple areas in the kitchen, kitchen equipment and food storage areas that were not clean. 4. Dietary staff was storing food ingredients in trash bags; and 5. Dietary staff were storing personal items in food storage areas. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash was found outside on the floor surrounding the dumpster. And the lids of the dumpsters did not close properly. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control and prevention program when: 1. There was no documented evidence that the screening questionnaires regarding signs and symptoms (S/S) of Coronavirus (COVID-19, a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic transmission) and vaccination status of each visitor/staff had been reviewed by a facility representative from 4/1/2022 until 4/14/2022 [14 days]. This failure placed all residents, visitors and staff who entered the facilitity from 4/1/2022 until 4/14/2022 at risk for COVID-19 . 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and comfortable environment when the window sills were separating from the window's wooden frame exposing nails, splinters and letting in outside air for two of 34 resident rooms (room [ROOM NUMBER]B and room [ROOM NUMBER]B). This failure placed Resident 20 and Resident 30 at risk for splinters and nail injuries and placed Resident 20 and 30 at risk for increased hot and cold temperatures.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and/or implement a comprehensive person-centered care plan for five of 15 sampled residents (Residents 158, 24, 25, 26, and 8) when: 1. Resident 158's use of dentures were not care planned. This failure resulted in Resident 158 not enjoying her food due to being on a puree diet and having her needs not met. 2. The hospice status (the type of care provided at the end of life and centered on promoting comfort and pain-free existence) for Resident 24 and Resident 26 was not care planned. These failures had the potential for the hospice needs for Resident 24 and 26 to go unmet. 3. Resident 25 care plan for site dressing change for tube feeding was not followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided meet professional standard of practice for one of four sampled residents (Resident 42) when facility staff did not follow the physician's order to administer continuous oxygen via nasal cannula (a device used to deliver supplemental oxygen). This failure had the potential to cause Resident 42 to experience shortness of breath, headache, weakness, and trouble sleeping.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent when 15 medication errors were observed during 27 medication administration opportunities, which resulted in an error rate of 55.56 percent. These failures resulted in Resident 8 and Resident 30 not being informed of the medications being administered and had the potential for unsafe medication administration and untherapeutic medication effects for Resident 8 and Resident 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Food and Nutrition Director (FND) did not follow manufacture temperature guideline for testing the Quaternary (Quat) ammonia sanitizer. 2. [NAME] 2 was unable to properly calibrated the thermometer. 3. [NAME] 1 did not follow the recipe for making Cabbage and carrots. Failure to ensure staff competency may result in resident exposure to bacterial growth associated with foodborne, incorrect and/or holding temperatures and practices that affect meal palatability to a population of Fifty three of 57 residents who received food from the kitchen and are medically compromised.

Inspectors wroteBased on meal delivery observation, resident and staff interview, and record review, the facility failed to follow its policy on Meal Service to provide appetizing food at appropriate temperatures according to residents' preferences for four of fifty-three sampled residents (Resident 24, Resident 50, and Resident 53 and Resident 158). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate documentation of medical records in accordance with accepted professional standards of practices for one of 15 sampled residents (Resident 58) when: 1. Licensed Vocational Nurse (LVN) 5 did not conduct a complete assessment and accurately document Resident 58's medical condition. 2. Certified Nurse Assistant (CNA) 2 did not complete and accurately document Resident 58's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's body functions). These failures resulted in inaccurate documentation and resulted in delayed treatment for Resident 58.

Inspectors wroteBased on observation, interview and record review the facility failed to provide care consistent with professional standards of practice for one of 15 residents (Resident 25) when: 1. Resident 25's gastrostomy tube (G-tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feeding was not changed in accordance with the physician orders. 2. Resident 25's G- tube dressing was not changed daily in accordance with the physician orders. These failures had the potential for Resident 25 to receive inadequate nutrition via the G-tube feedings and had the potential for Resident 25 to develop gastrointestinal issues and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care services in accordance with their policy and procedure titled, Oxygen Administration, when the oxygen tubing was not changed as ordered for one of 15 sampled residents (Resident 35). This deficient practice had the potential for Resident 35 to develop a respiratory infection.

Inspectors wroteBased on interview, and record review, the facility failed to conduct adequate monitoring for one of 15 sampled residents (Resident 54) when bupropion (a medication used to treat depression) was not appropriately monitored for negative effects. This failure had the potential to cause serious negative effects to Resident 54, including but not limited to changes in mood, thoughts of suicide, fast heartbeat, muscle pain, seizures, constipation, weight gain or weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Food and Nutrition Director (FND) effectively monitored the dietetic service operations in accordance with the Dietary Service Manager job description. This failure had the potential to result in ineffective and inadequate directing of the day-to-day foodservice operations to ensure the nutritional needs fifty three of 57 residents were met in a safe and sanitary manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's food preferences were honored for one of 57 sampled residents (Resident 158) when beef was placed on Resident 158's lunch plate, despite beef being listed as a dislike. This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, further compromising Resident 158's nutritional and medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's prescribed diet order, regular diet, regular texture, for one of 57 sampled residents (Resident 33) during lunch on 4/13/22 which result in Resident 33 receiving the wrong prescribed lunch meal. This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, further compromising the nutritional and medical status of Resident 33.

Inspectors wroteBased on observation during the survey period of 4/12/22 to 4/15/22, the facility failed to provide the minimum of at least 80 square feet per resident in 18 out of 34 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19). This failure had the potential for residents in Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19 to not have reasonable privacy or adequate space.