Valley View Care Center

Inspectors wroteThis citation pertains to intake 3064222. Based on observation, interview, and record review the facility failed to ensure a sit-to-stand lift (mechanical mobility device that helps transition a resident from sitting to standing) was used correctly for 1 (Resident #1) of 3 residents reviewed for falls resulting in a fall, right femur (thigh bone) fracture (broken bone), increased pain, and a hospitalization to have a fracture surgically repaired.

Inspectors wroteThis citation pertains to intake 3064222. Based on interview and record review the facility failed to ensure a resident's responsible party/power of attorney was notified immediately following a fall with injury for 1 (Resident #1) of 3 residents reviewed for notifications resulting in a responsible party not being kept updated on a resident's condition and changes.

Inspectors wroteBased on interview and record review, the facility failed to perform First Aid and Cardiopulmonary Resuscitation (CPR) per the standards of practice in 1 (Resident #140) of 4 residents reviewed for death resulting in an Immediate Jeopardy when on [DATE] at approximately 7:10 am, Resident #140, whose advanced directive indicated he was a full code (every possible life-saving therapy if a serious event occurs, such as cardiac or respiratory arrest) was found by facility staff in a pool of blood and without a heartbeat. Neither First Aid nor CPR was initiated, and Resident #140 was pronounced dead by Emergency Medical Services (EMS) at 7:36 AM. This deficient practice placed 67 residents that reside in the facility with the status of full code at risk or serious harm, injury, impairment, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident mental and verbal abuse for 2 (Resident #19 and Resident #96) of 3 residents reviewed for abuse, resulting in Resident #19 experiencing verbal threats and having profanity directed toward him by Resident #96.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adaptive dining equipment was provided consistently for 3 (Resident #62, 132, and 102) of 27 residents reviewed for dining resulting in decreased independence with dining, difficulty eating/drinking, and the potential for dehydration and/or weight loss.

Inspectors wroteBased on interview and record review, the facility failed to report injuries of unknown origin to the State Agency in a timely manner for 2 (Resident #19 and Resident #96) of 3 residents reviewed for abuse and reporting, resulting in the potential for ongoing mistreatment to go unrecognized.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and consistent ADL (activities of daily living) care to 1 resident (Resident #117) of 13 residents reviewed for ADL care, resulting in inadequate incontinence care and repositioning for meals and the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance.

Inspectors wroteThis citation pertains to intake 2660756. Based on interview and record review, the facility failed to ensure that residents received necessary treatments and care for diabetes in accordance with professional standards of practice for 1(Resident #142) of 27 residents reviewed for quality of care resulting in Resident #142 missing blood glucose monitoring and insulin (a hormone produced in the pancreas, which regulates the amount of glucose in the blood) which placed Resident #142 at risk for serious health complications.

Inspectors wroteThis citation pertains to 2660756 Based on interview and record review, the facility failed to ensure the physician notes reflected accurate representation of the resident's current condition and meaningful assessments of the residents' condition were completed for 1 (Resident # 142) of 27 residents reviewed for quality of care resulting in the lack of coordination of care and insufficient treatment for diabetes mellitus (a chronic disease where the body either doesn't make enough insulin or doesn't use it properly, leading to high blood sugar levels).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Contact Precautions (Transmission based measure implemented to a resident known or suspected to be infected with a microorganism that can be transmitted by direct contact with other residents or indirect contact with environmental surfaces) were effectively in place for 1 resident (#1), and ensure that standard infection control practices were properly implemented for 2 residents (Resident #3 and #117) from a total of 5 residents reviewed for infection control practice, resulting in the potential for transmission of MDRO (multidrug-resistant organisms) and cross contamination of bacteria to a suspectable population.

Inspectors wroteThis citation pertains to intake #2614156. Based on interview and record review the facility failed to adequately supervise, ensure safety and prevent an elopement of 1 (Resident #100) of 3 residents who were assessed to be at risk for elopement, resulting in an Immediate Jeopardy when Resident #100 left the premises on 8/30/25, alone, unbeknownst to staff and was returned on 8/31/25 after being missing for approximately 17 hours. The deficient practice placed all 17 residents a risk for elopement at risk for serious harm, serious injury, and/or death.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to promote dignity and respect in 2 (Resident #106 and #107) of 3 residents reviewed for dignity/respect, resulting in feelings of frustration and the potential for decreased self-esteem and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to maintain Quality Assurance and Performance Improvement Program (QAPI) that developed and implemented effective corrective actions and conduct meaningful surveillance to prevent adverse effects from medication erros in 2 of 2 residents (Resident #2 and Resident #9) reviewed for QAPI, resulting in the potential for serious adverse outcomes for all residents who receive medications from facility staff.

Inspectors wroteThis citation pertains to intake# MI001500378 Based on observation, interview and record review, the facility failed to follow the court appointed resident representative decisions as the rights of the resident who was adjudged incompetent by the court in 1 (Resident #4) of 1 resident reviewed for abuse, resulting in Resident #4 (who functioned at the level of a 6 year old child) experiencing feelings of frustration, confusion, and anger after witnessing ongoing conflict between facility staff and her family members/representatives.

Inspectors wroteThis citation pertains to Intake #MI00149109 Based on interview and record review the facility failed to maintain professional standards of nursing practice related to medication administration for 2 (Resident #2 and Resident #9) of 11 residents reviewed or professional standards of nursing practice resulting in both Resident #2 and Resident #9 being administered another resident's medications.

Inspectors wroteThis citation pertains to Intake #MI00149109 Based on observation, interview, and record review the facility failed to ensure that residents were free from significant medication errors in 2 (Resident #2 and Resident #9) of 2 residents reviewed for significant medication errors resulting in Resident #2 experiencing an altered level of consciousness, lethargy (decreased alertness and response), decreased oral intake, decreased blood pressure, and the need for supplemental oxygen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff implemented infection control measures by: 1). Implementing enhanced barrier precautions (EBP) for a resident with a urinary catheter in 1 (Resident #2) of 1 resident reviewed for EBP implementation and 2.) provide adequate storage of a CPAP (continuous positive airway pressure) mask for 2 (Resident #5 and Resident #6) of 2 resident reviewed for CPAP mask use, resulting in the potential for the introduction of infection, cross contamination, and disease transmission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, or serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents who consume food from the kitchen.

Inspectors wroteThis citation pertains to intake MI00146660. Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs for 6 (Resident #19, Resident #20, Resident #71, Resident #333, Resident #51, and Resident #60 ) of 3 residents and residents from the confidential group interview reviewed for staffing, from a total sample of 27 residents, resulting in long call light wait times and resident care needs not being consistently met with the potential for unmet care needs for all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted and resident dignity in 2 (Resident #60 and #71) of 3 residents reviewed for dignity, resulting in the potential of feelings of humiliation, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 2 (Resident #82 & #126) of 27 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate code status (a physician's order that determines the type of medical treatment a person will receive if their heart or breathing stop) was in place for 1 (Resident #62) of 27 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments in 1 (Resident #131) of 27 residents reviewed for accuracy of assessments, resulting in an inaccurate reflection of the resident's discharge status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to confirm the Pre-admission Screening and Resident Review (PASARR) Level II determination request was sent to the Community Mental Health Services Program (CMHSP) for a Level II OBRA review and/or evaluation for 2 (Resident #49 and #26) of 3 residents, resulting in the potential for the residents to not receive or have delayed mental health services.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive, person-centered care plan for 1 (Resident #11) of 3 residents reviewed for pressure ulcer prevention, resulting in an incomplete reflection of the resident's care and monitoring needs for pressure ulcer preventative

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive care plan with new interventions after a fall in 1 (Resident #15) of 2 residents reviewed for falls resulting in an inaccurate reflection of the resident's care needs and the potential for unmet medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL), specifically personal hygiene and getting out of bed were provided for 2 (Resident #19 & #20) of 4 residents reviewed for ADL care, resulting in unmet care needs and the potential for avoidable declines in overall health and wellness.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent skin breakdown for residents at risk for pressure ulcers, for 1 (Resident #20) of 5 residents reviewed for pressure ulcers, resulting in the potential for the development of an avoidable pressure ulcer, infection, and overall deterioration in health status.

Inspectors wroteThis citation pertains to intake MI00146660. Based on interview and record review, the failed to ensure documentation of resident medical records were completed for 2 (Resident #17 and #43) residents, of total sample of 27, reviewed for comprehensive and accurate medical records, resulting in an inaccurate reflection of the resident's medical treatments administered resulting in the potential for providers to not have an accurate picture of resident status and condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for proper hand hygiene, maintain clean resident wheelchairs for 2 (Resident #79, #40) of 2 residents, and sanitize resident shared equipment creating unsanitary conditions for commonly touched/utilized items reviewed for infection control practices resulting in the potential for the spread of infection, cross-contamination, and disease transmission for all residents residing in the facility.

Inspectors wroteThis citation pertains to intake MI0014870. Based on interview and record review, the facility failed to prevent significant medication errors for 2 (R102 and R105) of 3 residents reviewed for medication errors, resulting in a change in condition, emergent transfer, and hospitalization for R102 and the potential for change in condition for R105.

Inspectors wroteThis citation pertains to intake MI0014870. Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 5 residents (R102) reviewed for notification of changes, resulting in the resident representative not being made aware of a seizure, resulting in the lack of ability to participate in timely medical decision-making.

Inspectors wroteThis citation pertains to MI00142998. Based on interview and record review, the facility failed to report mistreatment to the State Agency for one (Resident #101) of three residents reviewed for abuse, resulting in the potential for the resident not being protected from abusive individuals.

Inspectors wroteThis citation pertains to MI00142998. Based on interview and record review, the facility failed to ensure the protection of other residents by thoroughly investigating allegations of mistreatment for one (Resident #101) of three reviewed for abuse, resulting in the potential for abuse to occur with other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1.) provide appropriate wound care treatment and preventions for 2 residents (Resident #112 and #4) of 2 residents reviewed for non-pressure related skin conditions and 2.) adequately identify and monitor a foot injury for 1 resident (Resident #109) of 1 resident reviewed for accident hazards, resulting in the actual worsening of diabetic ulcers for Resident #112, the potential of worsening wounds for Resident #4, and a delay in treatment for a foot injury for Resident #109.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity and respect in 1 (Resident #87) of 3 residents reviewed for dignity and respect, resulting in feelings of frustration.

Inspectors wroteBased on interview and record review, the facility failed to resolve resident concerns for 1 (Resident #87) of 1 sampled residents reviewed for resolution of concerns resulting in feelings of frustration and a potential decline in psychosocial and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to report a incident of neglect (failure to follow the care plan) causing rib fractures in 1 resident (Resident #79) of 3 resident reviewed for accidents, resulting in a fall with major injury after staff did not follow a care plan and it was not reported to the state survey agency within the two-hour required timeframe.

Inspectors wroteBased on interview and record review, the facility failed to ensure an annual Level I evaluation was completed for 1 (Resident #82) of 3 residents reviewed for Preadmission Screening and Resident Review (PASARR), resulting in the potential for unmet mental health and psychiatric care needs.

Inspectors wroteThis citation pertains to intake MI00137950. Based on interview and record review the facility failed to administer prescribed medication in a timely manner after admission for 1 resident (Resident #329) of 6 residents reviewed for medication orders, resulting in the resident not receiving prescribed medication for over 24 hours and the potential for the resident to not meet her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide consistent, meaningful, and person-centered activities for 1 resident (Resident #67), from a total sample of 26 residents, resulting in the potential for loss of interaction, connectedness, creativity, pleasure, and comfort.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received proper treatment to maintain hearing abilities for 1 of 1 resident (Resident #44), reviewed for hearing services, resulting in the inability of the resident to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide preventative care consistent with professional standards of practice and follow physician ordered treatment for pressure injury/wound care, for 3 of 3 residents (Resident #67, #21 and #79) reviewed for pressure ulcers, resulting in the potential for development of avoidable pressure ulcers for Resident #67, the potential for worsening and/or recurrent pressure ulcers for Resident #21, the delay in wound treatment for Resident #79.

Inspectors wroteBased on interview and record review, the facility failed to provide maintain the safety and implement the care plan causing a fall in 1 of 3 residents (Resident #79) reviewed for accidents, resulting in a fall to the floor from the bed and rib fractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide thickened liquids for 1 resident (Resident #122) of 2 residents reviewed for nutrition, resulting in the potential for aspiration and the resident to not meet her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to Intake # MI00139511. Based on interview, and record review, the facility failed to identify and eliminate/mitigate triggers related to a history of abuse/trauma in 1 of 1 resident (Resident #47) reviewed for trauma-informed care, resulting in the potential for re-traumatization.