Valley View Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of three sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #1 with the supervision necessary to prevent elopement.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect and exploitation for six (#1, #4, #3, #2, #8 and #7) of eight residents reviewed out of 13 sample residents. Specifically, the facility failed to: -Protect Resident #1 from physical abuse by Resident #8; -Protect Resident #4 from physical abuse by Resident #9; -Protect Resident #3 and Resident #8 from physical abuse by each other; -Protect Resident #2 from physical abuse by Resident #10; and, -Protect Resident #7 and Resident #8 from physical abuse by each other.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#3) of three residents at risk for elopement out of 17 sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #3 with the supervision necessary to prevent elopement. The facility's failures created a situation for the likelihood of serious harm to residents' health and safety if not immediately corrected. The facility was a totally secure building specializing in serving residents with severe mental illness, dementia and behavioral health issues. The entire campus had a six-foot high security fence around the whole campus with a wired overhang in the unrestricted front resident space to discourage anyone from climbing over the fence. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment that included all resources, education, staff competencies and facility based risk assessments for a facility that was a totally secured locked facility for residents with mental illness and dementia diagnosis. Cross-reference F689: failure to prevent a resident from eloping a secured locked facility.

Inspectors wroteBased on record review and interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment in seven of 26 resident rooms and damaged areas in one of two resident halls out of two units. Specifically, the facility failed to: -Ensure blinds were intact in seven resident rooms; and, -Ensure the heating vents were intact and not falling off the heating units.

Inspectors wroteBased on record review and interviews, the facility failed to ensure five (#1,#7, #4, #10 and #3) of 15 residents reviewed for abuse were kept free from abuse out of 17 sample residents. Specifically, the facility failed to: -Protect Resident #1 from physical abuse by Resident #6 and Resident #2; -Protect Resident #7 from physical abuse by Resident #2; -Protect Resident #4 from physical abuse by Resident #5; -Protect Resident #10 from physical abuse by Resident #11; and, -Protect Resident #3 from verbal abuse by a staff member.

Inspectors wroteBased on record review and interviews, the facility failed to establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf for one (#8) of four residents reviewed for personal funds out of 17 sample residents. Specifically, the facility failed to provide Resident #8 a copy of her personal funds statement on at least a quarterly basis.

Inspectors wroteBased on observations and interviews, the facility failed to provide a meal service for residents in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for residents served in two of two dining rooms. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served and seated in the dining room. I. Facility policy The Frequency of Meals policy, revised July 2017, was provided by the nursing home administrator (NHA) on 5/15/24 at 1:27 p.m. It read in pertinent part, The facility will serve at least three meals or their equivalent daily at scheduled times. Meals will be served four to six hours apart to help assure that residents receive nutritional requirements. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure the walk-in refrigerator maintained a safe operating temperature of 41 degrees Fahrenheit (F) or below to prevent food from spoiling; and, -Ensure all damaged tiles were repaired to ensure all surfaces in the kitchen were cleanable.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#10) of fifteen residents reviewed for choices out of 32 sample residents remained free of resident right restrictions in order to promote and facilitate resident self- determination. Specifically the facility failed to ensure Resident #10 received baths consistently according to his choice of frequency and bathing preference.

Inspectors wroteBased on record review and interviews, the facility failed to incorporate the recommendations from the PASRR (preadmission screening and resident review) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#2) of five residents out of 32 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommend in Resident #2 's PASRR Level II report; and, -Ensure the PASRR recommendations were included in Resident #2 's care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#23) of five residents reviewed for ancillary services out of 33 sample residents received routine dental care and 24-hour emergency dental care. Specifically, the facility failed to refer Resident #23 to the dentist to obtain dentures timely.

Inspectors wroteBased on interviews and observations, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the main kitchen. Specifically the facility failed to: -Ensure the kitchen's oven was maintained to function properly; -Ensure two of six burners were functioning properly; and, -Ensure the kitchen oven door was repaired to ensure the oven maintained consistent and appropriate cooking temperatures for cooked food.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for two (#1 and #2) of four residents reviewed out of four sample residents. Specifically, the facility failed to: -Notify the physician timely when a pressure ulcer was discovered and implement timely treatment orders for Resident #1; and, -Accurately complete a weekly skin assessment to reflect the Resident #1 and Resident #2's skin impairments.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#1) out of three sample residents were kept free from abuse. Specifically, the facility: -Failed to prevent a resident-to-resident altercations between Resident #1 and #2.

Inspectors wroteBased on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week. Specifically, the facility did not have a RN between 1/13/23 to 1/19/23.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure the dishwasher maintained sufficient levels of water temperature and sanitizing solution.

Inspectors wroteBased on observations and interviews, the facility failed to have an individual designated as an infection preventionist who had completed specialized training in infection prevention and control. Specifically, the facility had not had an infection preventionist (IP) employed since August 2022.

Inspectors wroteBased on observations and interviews, the facility failed to provide a meal service for residents in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for residents served in two dining rooms. Specifically, the facility failed to: -Ensure residents had complete access to the dining room and ensure dining room doors were not locked during meal times; and, -Ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be seated in the dining room.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 12 of 26 resident rooms, three of three hallways and kitchen. Specifically, the facility failed to ensure walls, baseboard coves, halls, floors, handrails, and ceiling tiles were repaired, painted and properly maintained.

Inspectors wroteBased on interviews and record review the facility failed to prevent resident to resident altercations for six (#42, #40, #7, #17, #20 and #59) of six residents out of 21 sample residents. Specifically, the facility failed to prevent resident to resident physical abuse altercations between: -Resident #42 and Resident #40; -Resident #7 and Resident #17; and, -Resident #20 and Resident #59.

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies prior to providing skilled services as described in the plan of care for six out of six CNAs reviewed for competencies.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of two medication carts, and one of one medication storage rooms. Specifically, the facility: -Failed to discard an expired vial of tuberculin; -Failed to date a vial of tuberculin when opened; and, -Failed to date a Breo inhaler and Advair inhaler when opened.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure medical records were kept in a secure and confidential manner and the medical record was complete and accurate in keeping with accepted standards of practice for three (#54, #32 and #41) of five residents out of 21 sample residents. Specifically, the facility failed to keep all medical records for Resident #54, #32, and #41 information complete and accurate.

Inspectors wroteBased on interviews and record review, the facility failed to conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests all for 21 sample residents. Specifically, the facility failed to document in the resident records the results of COVID-19 tests for residents.

Inspectors wroteBased on interviews and record review, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning and transitions of care for two (#54 and #41) out of five residents reviewed for PASRR out of 21 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommended in the resident's PASRR level II for Resident #54; and, -Notify the state mental health agency recommendations could not be met for Resident #54 or #41.

Inspectors wroteBased on interviews and record review, the facility failed to notify the state mental health agency promptly after a significant change in the mental condition of three (#54 and #32) of five residents out of 21 sample residents. Specifically, the facility failed to notify the state mental health agency of Resident #54 and Resident #32 necessity for inpatient psychiatric hospitalizations.

Inspectors wroteBased on record review and interviews, the facility failed to provide services that met professional standards of quality according to accepted standards of practice for one (#50) of five residents reviewed of 21 sample residents. Specifically, the facility: -Failed to communicate with other staff the care and treatment for a skin tear for Resident #50, and, -Failed to follow facility policy and write a treatment order received by the provider for Resident #50.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide services by qualified persons for one (#42) out of 21 sample residents. Specifically, the facility failed to ensure Residents #42 was assessed by a registered nurse (RN) following a fall.

Inspectors wroteBased on interviews, observations and record review, the facility failed to provide the necessary assistance with activities of daily living (ADL) for two (#54 and #32) out of five residents reviewed for ADLs out of 21 sample residents. Specifically, the facility failed to provide bathing according to the resident's preferences for Resident #54 and #32.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) receives the necessary services and assistance for bathing for one (#50) of four residents reviewed for bathing assistance of 21 sample residents. Specifically, the facility failed to provide bathing for Resident #50.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#2) of three residents reviewed for the use of supplemental oxygen of 21 sample residents. Specifically, the facility -Failed to ensure oxygen was administered according to physician orders for Resident #2, and -Failed to have a system in place to communicate oxygen concentrator settings for staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess/reassess, obtain consent, and review the risks and benefits for using side rails (transfer bars) with the resident/resident representative for one (#42) of one resident reviewed for use of bed rails for positioning use out of 21 sample residents. Specifically, the facility failed to assess and review the risk and benefits for using side rails (transfer bars) prior to the use by Resident #42.

Inspectors wroteBased on record review and interviews, the facility failed to two (#54 and #41) residents of five were free from unnecessary psychotropic medications out of 21 sample residents. Specifically, the facility failed to ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #54 and #41.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#42) of two residents reviewed for hospice services out of 21 sample residents. Specifically, the facility failed to: -Have a written agreement for Resident #42 that included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the nutritional and hydration needs were consistently met for two residents (#13 and #15) of three out of 26 sample residents. Specifically, the facility failed to implement interventions to prevent a significant weight loss for Resident #13 who was at nutritional risk due to poor nutritional intake and who required staff assistance for cueing at meals. The facility failed to identify assistance needed with meals in timely manner and address Resident #13's nutritional needs. Lack of timely interventions to aid Resident #13 to maintain her nutritional status led to a significant, unplanned weight loss of 13.4% in four months. In addition, the facility failed to ensure Resident #15 had consistent weekly weights obtained and implement interventions when Resident #15 had weight loss.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to be free from physical abuse for five (#2, #15, #25, #40 and #47) of seven residents out of 26 sample residents. Specifically, the facility failed to ensure: -Residents #2, #15 and #47 were kept free from abuse by Resident #29; -Resident #40 was kept free from abuse by Resident #9; and, -Resident #25 was kept free from abuse by Resident 40. I. Facility policy and procedure The Abuse policy, last revised November 2019, was provided by the regional health information manager ([NAME]) on 11/29/21 at 12:00 p.m. It read in pertinent part, Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Employees have a unique position of trust with vulnerable residents. [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure residents received their meals in a timely manner and the facility failed to have substantial nourishing snacks available. Specifically, the facility failed to ensure: -There were not more than 14 hours between a substantial evening meal and breakfast the following day; and, -Nourishing snacks were offered to residents at bedtime.

Inspectors wroteBased on observation, and interviews the facility failed to follow infection control measures to prevent the potential cross contamination of SARS-CoV-2 COVID-19, with two (#2 and #13) of two residents out of 26 sample residents. Specifically, the infection preventionist (IP) failed to wear proper personal protective equipment (PPE), a protective gown, consistently when collecting SARS-C0V-2 COVID-19 specimens from two residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain meal assistance for two residents (#13 and #5) of three residents reviewed out of 26 sample residents. Specifically, the facility failed to ensure Resident #13 and #5 received assistance with meals and fluid intake.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure it was free of medication error rates of five percent or greater for two (#3 and #35) of four residents observed during medication administration. Specifically, there was an error rate of 6.67% percent with two errors out of 30 opportunities for error.