Valley View Health & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Resident #10, #9, and #13), in a review of 13 sampled residents, were treated with dignity and respect. Certified Medication Technician (CMT) F was rude and rough during care for one resident, (Resident #10) and the resident said it hurt his/her feelings and made him/her feel angry. CMT F was rough and forceful with Resident #9's care and the resident said it made him/her feel like he/she wasn't worth anything. Resident #13 reported CMT F was condescending and liked to show his/her authority; the resident said it made him/her so angry he/she wanted to punch CMT F in the face. The facility census was 76. Review of the facility's policy Resident Rights, revised December 2016, showed all employees should treat all residents with kindness, respect, and dignity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided assistance with Activities of Daily Living (ADLs) for two residents (Resident #1 and #7) in a review of 13 sampled residents, to maintain proper grooming to include nail care and personal hygiene. The facility census was 76. Review of the facility's policy Activities of Daily Living (ADL), Supporting, revised March 2018, showed the following: -Resident's will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal and oral hygiene; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide protective oversight to ensure one resident (Resident #1), did not obtain a lighter and cigarettes within the facility on multiple occasions. The resident was also observed smoking in his/her room wearing oxygen and admitted to staff he/she was smoking in the facility. Staff educated the resident not to smoke in the building and on the smoking policy. There was no documentation any other interventions were put in place or the resident's smoking assessment was updated until 2/19/25. On 2/20/25 during the night, the resident was observed smoking and admitted to smoking in the facility on more than one occasion and was found with two lighters and a half pack of cigarettes. The facility census was 76. Review of the facility's policy titled, Smoking Policy, dated 10/2/24, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff adequately documented assessments and monitoring of pressure ulcers (any lesion caused by unrelieved pressure, resulting in damage to underlying tissue that usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed) for one resident (Resident #333), in a review of 22 sampled residents; failed to maintain documentation of communication with the resident's physician on the changes to the resident's pressure ulcers to ensure appropriate treatment and care of the pressure ulcers; failed to ensure the resident's physician or designee followed facility policy to examine the resident's pressure ulcers upon readmission to the facility and to evaluate and document the progress of the pressure ulcers during resident visits; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff safely transferred two residents (Residents #133 and #21), in a review of 22 sampled residents and one additional resident (Resident #30), who required assistance with transfers. Staff failed to utilize proper transfer technique when transferring Resident #133, when staff did not use a gait belt and did not ensure the resident wore proper foot wear during a transfer which resulted in a fall with injury. The resident sustained a displaced fracture of the tibia/fibula (ankle) as a result of the fall. The facility census was 84. Review of the facility policy, Managing Falls and Fall Risk, revised [DATE], showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served to residents in a safe and sanitary manner when staff failed to utilize proper hand hygiene and gloving techniques, hair restraint usage, surface sanitation, food storage, and dish handling and storage. The facility census was 84. 1. Review of the facility policy, Food Preparation and Service, revised 4/2019, showed the following: -Food and nutrition services employees will prepare and serve food in a manner that complies with safe food handling practices; -Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays; -Gloves are worn when handling food directly and changed between tasks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to prevent the development and transmission of diseases and infections for four residents (Residents #21, #40, #283, and #31), in a review of 22 sampled residents, and four additional residents (Resident #71, #38. #79 and #50). Staff failed to perform appropriate hand hygiene during personal care for Residents #21 and #71; failed to utilize Enhanced Barrier Precautions (EBP) during personal care for Resident #71 who had a gastrostomy tube (a flexible tube that is surgically inserted through the abdominal wall and into the stomach that allows for the delivery of nutrition and medication directly into the stomach); failed to ensure Resident #40's urinary catheter (tube inserted into the bladder to excrete urine from the body) drainage bag was stored off the floor; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral hygiene for two residents (Residents #41 and #48), who required assistance with oral care, in a review of 22 sampled residents. The facility census was 84. Review of the facility's policy, Mouth Care, revised February 2018, showed the following: -Purpose of the procedure was to keep the resident's lips and oral tissues moist, to cleanses and freshen the mouth, and to prevent oral infection; -The following should be documented in the resident's medical record; -1. The date and time the mouth care was provided along with the name and title of the individual who provided the mouth care; -2. Complaints of pain or discomfort of the mouth; -3. If the resident refused the treatment, the reason why, and the intervention taken; -4. The signature and title of the person recording the data. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director or his/her designee attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis. The facility census was 84. Review of the facility's QAPI Plan, dated March 2020, showed the following: -The Quality Assessment and Assurance (QAA) committee was designed to address quality deficiencies through analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level; -QAA committee was responsible for analyzing identified problems, establishing, corrective actions, measuring progress against the established goals and benchmarks, and communicating information to staff and residents and reporting findings to the administrator and governing board; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident #2 and #7) in a review of seven sampled residents, who the facility identified as dependent on staff for Activities of Daily Living (ADLs), received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental and psychosocial needs. Staff failed to ensure Resident #2 was kept clean and dry, repositioned in bed, provided access to a call light, and had access to water and fluids. Staff also failed to provide incontinence care to Resident #7 for over seven hours when the resident had informed staff. Instead of providing care, staff covered the resident's soiled bed linens with a towel. The facility census was 84. Review of the facility policy, Activities of Daily Living (ADL), Supporting, dated March 2018, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident, in a review of seven sampled residents (Resident #2), who had an indwelling urinary catheter (a flexible tube inserted into the bladder to allow urine to drain from the bladder), and who had a history of urinary tract infections (UTI), was provided with urinary incontinence care and indwelling catheter care in a manner to prevent the spread of bacteria that cause infections. The facility had 12 residents with indwelling urinary catheters. The facility census was 84. Review of the facility policy Urinary Catheter Care dated September 2014, showed the following: -The purpose was to prevent catheter-associated urinary tract infections; -Use standard precautions when handling or manipulating the drainage system; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for one resident (Residents #2), in a review of seven sampled residents. The facility census was 84. Review of the facility policy Handwashing/Hand Hygiene, dated August 2019, showed the following: -The facility considered hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent misappropriation of three residents' (Resident #1, #2 and #3) narcotic pain medication when certified medication technician (CMT) A removed one hydrocodone-acetaminophen (a combination medication used to relieve pain containing an opioid pain reliever and a non-opioid pain reliever) 5 milligrams (mg)/325 mg pill from Resident #1's and #3's narcotic medication card and removed two hydrocodone 10 mg/325 mg pills from Resident #2's narcotic medication card and admitted to ingesting them while on duty. The facility census was 81. The administrator was notified on 3/6/24 of the past non-compliance which occurred on 2/27/24. On 2/27/24 the consulting pharmacist was at the facility conducting a random spot check of medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #3), in a review of five residents, from physical abuse when Licensed Practical Nurse (LPN) B witnessed Certified Nurse Assistant (CNA) A pushing down and holding Resident #3's arms that were crisscrossed on the resident's chest while the resident hollered out with a red face. LPN B noted red marks on the resident's wrist and forearm following the incident. The facility census was 85. On 1/11/24 at 2:00 P.M., the administrator was notified of the past noncompliance which occurred on 12/31/23. On 12/31/23, the administrator identified CNA A physically abused Resident #3. Upon discovery, staff suspended CNA A, conducted an investigation and notified appropriate parties. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment by failing to ensure residents' rooms and living spaces were clean and in good repair. The facility census was 67. 1. Observations on 11/07/22 at 10:55 A.M. and on 11/8/22 at 7:04 A.M. in occupied resident room [ROOM NUMBER] showed a strong urine odor. Observations on 11/8/22 at 10:31 A.M. and on 11/9/22 at 10:31 A.M. in the bathroom in occupied resident room [ROOM NUMBER] showed a strong urine odor. A soiled uncovered urinal, graduate, and bed pan were stored on the shelf above the toilet. 2. Observation on 11/08/22 between 8:00 A.M. and 2:50 P.M., during the life safety code tour of the facility, showed the following: -In the main dining room, eleven, 4-inch by 4-inch ceiling vents were covered in a thick layer of dust; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for three residents (Residents #17, #51, and #52), in a review of 22 sampled residents, and failed to practice clean technique during medication administration for one additional resident (Resident #31). The facility census was 66. Review of facility policy Handwashing/Hand Hygiene, last revised August 2015, showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infection; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; [...]

Inspectors wroteBased on interview and observation, the facility failed to provide proper care to a urinary catheter (a tube inserted in to the bladder to excrete urine out of the body), for one resident (Resident #17), in a review of 22 sampled residents, Nine residents had a urinary catheter. The facility census was 66. Review of the facility policy, Urinary Catheter Care, last revised September 2014, showed the following: -The purpose of the procedure was to prevent catheter-associated urinary tract infections; -Use a washcloth with warm water and soap to cleanse around the meatus (a part of the genitalia). Cleanse the glans (a part of the genitalia) using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify two residents (Residents #20, and #21), in a review of 22 sampled residents, one closed record (Resident #67), and one additional resident (Resident #11) and/or their representatives in writing of transfer to the hospital, including the reasons for the transfer. The facility census was 66. Review of the facility's Transfer or Discharge Documentation, revised December 2016, showed the following: -When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. -When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the facility name, resident census, and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility census was 66. Review of the facility policy, Posting Direct Care Daily Staffing Numbers, revised July 2016, showed the following: -Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) a federally mandated assessment instrument required to be completed by facility staff) for four residents (Residents #18, #5, #6, and #28) in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 64. 1. During interview on 5/3/19 at 3:55 P.M. the MDS Coordinator said he/she followed the Resident Assessment Instrument (RAI) 3.0 manual while completing residents' MDS. 2. Review of the Long Term Care Facility RAI User's Manual, version 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided three of 17 sampled residents (Resident # 52, #30 and #46) who were unable to complete their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 64. 1. Review of the facility policy Mouth Care dated 2/18 showed the purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and and to prevent oral infection. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Equipment and supplies: toothbrush, toothpaste, emesis basin, towel, fresh water, mouthwash, disposable cup, straw, applicators or gauze sponges, lubricants and personal protective equipment. [...]

Inspectors wroteBased upon interview and record review, the facility failed to offer bedtime snacks to residents. During the group interview all residents present (Residents #44, #24, #55, #49, #36, #47, #12, #7, #16 and #2) said staff did not deliver or offer snacks in the evening. The facility census was 64. 1. Review of the facility policy, Snacks (Between Meal and Bedtime), Serving, dated 2001 and last revised 9/14 showed the following: The purpose of this procedure is to provide the resident with adequate nutrition; Preparation: 1. Review the resident's care plan and provide for any special needs of the resident; 2. Assemble equipment and supplies needed. 3. Check the tray before serving the snack to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow; 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for five residents (Resident #6, #38, #39, #46 and #30) in a review of 17 sampled residents. The facility also failed to ensure staff appropriately disinfected a urine soiled mattress for one resident (Resident #46). The facility census was 64. 1. Review of facility policy Handwashing/Hand Hygiene last revised 8/15 showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infection; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two residents (Resident #38 and #39) urinary catheter (tube inserted into the bladder to drain urine) drainage bags and/or tubing were kept off the floor in a review of 17 sampled residents. Resident #38 had a significant history of urinary tract infections (UTIs) and sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to malfunctioning of various organs, shock, and death). The facility census was 64 . 1. Review of the facility policy, Catheter Care, Urinary dated 2001 and last revised 9/14 showed: Infection Control 1. Use standard precautions when handling or manipulating the drainage system. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one resident's (Resident #18) orders for as needed (PRN) psychotropic drugs were limited to 14 days as required except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration of the PRN order and failed to ensure one resident (Resident #30) who received multiple psychotropic medications (including three sedative type medications at bedtime), had any documented, attempted Gradual Dose Reductions to include the request, decision from physician and/or the rationale for the refusal. The facility census was 64. 1. During interview on 5/3/19 at 4:30 P.M. [...]