Valley View Care and Rehabilitation

Inspectors wroteBased on record review and interviews with residents, staff, Psychiatric Provider and the Medical Director the facility failed to implement effective systems to prevent an accidental overdose. On 7/02/26, staff found Resident #1 in his room pale, sweating, and incoherent and observed crushed pills and white powder on his television stand. Staff administered Narcan (a nasal spray that rapidly reverses opioid overdose), and within two minutes Resident #1 was able to answer questions and assist with transfer to the Emergency Medical Services (EMS) stretcher. [...]

Inspectors wroteBased on observations, record review, and staff and Medical Director interviews, the facility failed to provide care in a safe manner when staff assisted a resident with muscle weakness, dementia, and was bedbound with incontinence care. The resident fell off the side of the bed onto the floor, was bleeding from her head, and immediately transferred to the hospital for treatment. A hospital x-ray (imaging test for body's internal structures) revealed Resident #3 had suffered a laceration to the left side of the scalp and neck fractures during the fall. Resident #3 received treatment at the hospital on 5/30/26 and was discharged back to the facility on 5/31/26. The deficient practice occurred for 1 of 3 residents for the prevention of accidents (Resident #3).

Inspectors wroteBased on record reviews, and resident, staff, and Nurse Practitioner interviews, the facility failed to ensure medications were administered as prescribed by the physician when Medication Aide #1 administered medications to Resident #1 that were prescribed for Resident #2. The medications included doxepin (antidepressant), lamotrigine (anticonvulsant), folic acid (vitamin B9) and acetaminophen (analgesic). The deficient practice affected 1 of 3 residents reviewed for medication errors.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.5% for 1 of 2 residents observed during the medication administration (Resident #4).

Inspectors wroteBased on record reviews and interviews with staff and Nurse Practitioner, the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for significant medication error (Resident #1). Medication Aide #1 administered Lyrica (a medication that treats nerve pain by calming overactive nerves in your body and can also treat epilepsy by preventing and managing seizures) to Resident #1 that was prescribed for Resident #2, and that Resident # 1 had a documented allergy to. Resident #1 had no significant adverse reaction related to being administered the Lyrica.

Inspectors wroteBased on observations and interviews, the facility failed to clean the circulatory fan covers in the walk-in refrigerator and failed to dispose of food stored for use with signs of spoilage in the facility's walk-in refrigerator. This was for 1 of 3 refrigerators (walk-in) observed in the kitchen. The deficient practice had the potential to affect food served to residents. Findings Included:a. On 4/27/26 at 10:51 AM an observation in the walk-in refrigerator found the two circulatory fan covers with a buildup of greyish, clumpy and crumbly to touch substance. The substance was covering the 2 fan covers and would move when the fans were running.b. On 4/27/26 at 10:54 AM an observation in the walk-in refrigerator found a box of whole cucumbers located on the top shelf of a food storage rack. [...]

Inspectors wroteBased on observations, record reviews, and resident and staff interviews, the facility failed to maintain an intact headboard without rough edges (Resident #14) and maintain chair rail molding in good repair (Resident #14 and Resident #53). This deficiency occurred for 2 of 4 residents reviewed for safe, clean and homelike environment (Resident #14 and Resident #53) on 1 of 5 facility halls.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a comprehensive Care Area Assessment (CAA) to address the underlying causes and contributing factors of the triggered areas for 3 of 3 residents reviewed for comprehensive assessments (Resident #4, Resident #65 and Resident #9).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Resident #18 and Resident #4) and alarms (Resident #9) for 3 of 9 residents whose MDS were reviewed.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to repair a privacy curtain track which prevented the privacy curtain from extending around a resident's bed to provide total visual privacy. This deficient practice occurred for 1 of 19 residents reviewed for privacy (Resident #29).

Inspectors wroteBased on record review and staff interviews, the facility failed to review and update the Facility Assessment annually. This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on record review, staff, resident and Medical Director interviews, the facility failed to follow physician orders for checking a diabetic resident's blood glucose levels twice daily for 2 of 2 residents with physician orders for blood sugar monitoring (Resident #23 and Resident #17).

Inspectors wroteBased on record review, and staff, Medical Director, and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendations to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident (Resident #46) who received an antipsychotic medication. In addition, the facility failed to follow pharmacy recommendations that had been signed by the physician to add a 14-day stop date for a prn (as needed) psychotropic medication for a Resident #17. This deficient practice occurred for 2 of 5 residents reviewed for pharmacy recommendations (Resident #46 and Resident #17).

Inspectors wroteBased on record review, staff, Medical Director, and Consultant Pharmacist interviews, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment for a resident who received an antipsychotic medication (Resident #46). In addition, the facility failed to ensure a physician order for an as needed (prn) psychotropic medication was limited to 14 days (Resident #17). This deficient practice occurred for 2 of 5 residents reviewed for unnecessary psychotropic medications (Resident #46 and Resident #17).

Inspectors wroteBased on record reviews and staff interviews the facility failed to provide dental services for 1 of 1 (Resident #17) residents reviewed for providing emergency dental services.

Inspectors wroteBased on observations and interviews with residents and staff, the facility failed to maintain repair or replace damaged bed power cord for 2 of 12 ( Room#101 and Room#103) resident rooms on 1 of 4 resident halls reviewed for maintaining a safe, clean, and homelike environment.

Inspectors wroteBased on observations, record review, and staff and Medical Director interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) for a resident (Resident #23) with a feeding tube and a resident with a wound (Resident #32) when Nurse #1 failed to wear a gown while administering a tube feeding for Resident #23 and the Wound Care Nurse failed to wear a gown while performing wound care for Resident #32. This deficiency occurred for 2 of 2 staff members reviewed for infection control practices (Nurse #1 and the Wound Care Nurse).

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to maintain a resident's dignity by not providing assistance when requested by a resident (Resident #259) with a wet brief for 1 of 2 residents reviewed for dignity. Resident #259 stated this made her feel not too good, aggravated and worried that staff had forgotten her.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to provide sufficient nursing staff to assist residents with incontinence care, showers, bed baths and hair care, wound care, and to provide pneumococcal vaccines to eligible residents for 5 of 12 residents (Residents #259, #51, #13, #25, and #7) reviewed for sufficient staffing.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean kitchen floor, discard expired food items available for resident use in 1 of 1 walk-in cooler, label and date food in 1 of 1 reach-in refrigerator, maintain a clean refrigerator in 1 of 1 nourishment room on E Hall and maintain air vents free from dust buildup in the kitchen. These practices had the potential to affect food and beverages served to the residents.

Inspectors wroteBased on staff interviews, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect 56 of the 56 residents at the facility.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide completed Skilled Nursing Facility Advanced Beneficiary Notices (SNF-ABN) prior to discharge from Medicare Part A skilled services to 3 of 3 residents (Resident #47, Resident #23 and Resident #29) and failed to issue a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare part A stay for 1 of 3 residents (Resident #47) reviewed for beneficiary notification.

Inspectors wroteBased on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to transcribe a probiotic as ordered by the physician resulting in 6 months additional administration of probiotic for 1 of 5 sample residents reviewed for unnecessary medications (Residents #28).

Inspectors wroteBased on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 5 sample residents reviewed for unnecessary medications (Residents #28).

Inspectors wroteBased on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to discontinue a probiotic as ordered by the physician resulting in 6 months additional administration of unnecessary probiotic for 1 of 5 sample residents reviewed for unnecessary medications (Residents #28).

Inspectors wroteBased on observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident could access a light switch located behind her bed for 1 of 1 resident reviewed for accommodation of needs (Resident #1). Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's medical records revealed she had moved to her current room on 04/17/23. The significant change in status Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with moderate impairment in cognition. The MDS indicated walking between locations inside the room did not occur for Resident #1 during the assessment period. During an observation conducted on 10/30/23 at 10:15 AM, the switch for the light fixture behind Resident #1's bed on the wall approximately 5 feet from the floor and 5 feet from Resident #1's bed with a cord approximately 4 inches attached. [...]

Inspectors wroteBased on record review, observation, and resident and staff interviews, the facility failed to honor a resident request to have two showers per week for 1 of 1 resident (Resident #51) reviewed for choices.

Inspectors wroteBased on observation, record review and interviews with resident and staff, the facility failed to maintain a wheelchair in good repair for 1 of 2 residents reviewed for a safe comfortable, homelike environment (Resident #37).

Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to provide a complete bed bath and hair care to a dependent resident for 1 of 3 residents (Resident #13) reviewed for activities of daily living.

Inspectors wroteBased on observations, record review, resident, staff and Medical Director interviews, the facility failed to assess, obtain a physician's order and perform dressing changes for a weeping area on a resident's lower extremity for 1 of 1 resident reviewed for skin condition (Resident #25).

Inspectors wroteBased on record review, and staff interviews, the facility failed to administer the pneumococcal vaccine to eligible residents for 2 of 5 residents (Resident #259 and Resident #7) reviewed for immunizations.