Valley View Health Care Facility

Inspectors wroteBased on interview and record review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment upon discharge for 1 (Resident #23) of 5 sampled residents investigated for Resident Assessment.

Inspectors wroteBased on record reviews and interviews, the facility failed to transmit a completed MDS (Minimum Data Set) assessments within 14 days after completion for 1 (#8) of 1 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect the 77 residents who resided in the facility. The facility failed to ensure appropriate environmental cleaning and disinfecting solutions were used to disinfect surfaces throughout the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #78) of 25 sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure ADLs (activities of daily living) were performed for 1 (#57) of 4 residents reviewed for ADLs. The facility failed to ensure Resident #40 received nail care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide assistance with bathing for 1 (Resident #55) of 4 residents reviewed for ADLs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from staff to resident verbal abuse, for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Resident #3, a cognitive resident, experienced mental anguish and psychosocial harm as a result of the verbal abuse by staff. This deficient practice resulted in an actual harm for Resident #3 on 02/27/2025 at 12:54 p.m., when Resident #3 reported to the Administrator that while in the activity room, S3 LPN confronted her (Resident #3), engaged in a verbal altercation with her, and shouted at her to shut her mouth. Resident #3, who had a BIMS score of 15 (cognitively intact), stated she was tearful, scared, and nervous during and after the verbal altercation with S3 LPN. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of staff to resident verbal abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the staff to resident verbal abuse was discovered, for 1 (Resident #3) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Interview on 03/11/2025 at 3:51 p.m. with S1 ADM revealed on 02/27/2025 at 12:45 p.m., Resident #3 was verbally abused by S3 LPN. S1 ADM revealed this incident of staff to resident verbal abuse was witnessed by a Hospice Volunteer Coordinator and R1. Review of the SIMS (Statewide Incident Management System) report dated 03/06/2025 revealed the discovery date and time of verbal abuse for Resident #3 was on 02/27/2025 at 12:54 p.m. The SIMS entry time was documented as 02/28/2025 at 12:40 p.m. Interview on 03/11/2025 at 3:51 p.m. [...]

Inspectors wroteFACILITY Infection Control Based on observations, staff interviews and facility policy record reviews, the facility failed to maintain an Infection Prevention and Control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. These deficiencies had the potential to effect 73 residents that resided in the facility. The facility failed to: 1. Ensure the lint drawers on the clothes dryers and the washing machine filters were regularly cleaned; 2. Ensure proper PPE use and infection control measures were used when performing wound care for Resident #32; and 3. Have a water management program in place that specified testing protocols and acceptable ranges for control measure, and the results of testing and corrective actions taken when control limits were not maintained.

Inspectors wroteFACILITY Based on record review and interview the facility failed to accurately submit mandatory direct care staffing information, based on payroll, to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 3 2024 (April 1- June 30).

Inspectors wroteBased on observation, record review, and interview the facility failed to implement the resident's comprehensive plan of care for 1 (#48) of 22 sampled residents by failing to connect the clip alarm and monitor the alarm sounding sensor pad while Resident #48 was up in the wheelchair.

Inspectors wroteBased on record review and interview the facility failed to ensure a reportable unwitnessed and/or incident of unknown origin was reported to the State Agency for 1 Resident (Resident #2) of 3 sampled Residents (Resident #1, Resident #2, and Resident #3). The facility failed to report an incidence of Resident #2's injury of unknown origin.

Inspectors wroteBased on record review and interview the facility failed to ensure a reportable unwitnessed and/or incident of unknown origin was thoroughly investigated for 1 Resident (Resident #2) of 3 sampled Residents (Resident #1, Resident #2, and Resident #3). The facility failed to investigate an incidence of Resident #2's injury of unknown origin.

Inspectors wroteBased on interview, observation and record review, the facility failed to implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 resident (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure a positioning device was provided as ordered for Resident #1 with hand contractures.

Inspectors wroteDining Observation Based on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to provide meals to 2 of 4 Residents at a table, who were seated at the same time. Observation on 11/07/2023 at 11:25 a.m. revealed dining tables in Dining Room B were not served together. Two of the Residents in the dining room had been served a meal while two other Resident's seated at the same dining table without a meal tray. Observation on 11/07/2023 at 11:35 a.m. revealed two Residents being fed by CNAs in Dining Room B together and the other two Residents sitting at the same dining table waiting on their meal tray. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a residents' rights to be free from physical abuse for 1 (#31) of 3 (#31, #73 and #284) residents sampled for abuse, in a total sample of 28 residents. The facility failed to protect Resident #31 from physical abuse by Resident #284. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation.