Valley View Village

Inspectors wroteBased on observation, staff and resident interview, and clinical record review, the facility failed to ensure 1 of 4 residents (Resident #4) review for accidents/hazards, had the appropriate staff assistance for utilizing the elevator, as recommended by therapy. On 9/17/25 at approximately 9:30 AM, Chaplain Assistant supervised as Resident #4 attempted to turn an electric scooter around and exit the elevator independently. The Resident #4 sustained an injury to the lower left leg when the elevator door closed On 9/17/25 at 11:08 AM, following the incident, a Nursing Note revealed that Resident #4's leg was swollen with severe pain. The Resident #4 was transferred to the Emergency Department on 9/17/25 and was found to have a large hematoma to left lower leg. [...]

Inspectors wroteBased on record review, observations, resident and staff interviews and policy review the facility failed to provide adequate supervision to prevent an elopement for one of three wandering residents reviewed (Resident #79). The facility also failed to answer resident call lights within the allotted professional standard of 15 minutes for 3 of 5 residents reviewed (Resident #28, #83, and #84). The facility reported a census of 76 residents.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to handle and serve food in a sanitary manner to prevent cross-contamination for 2 of 2 meals observed. The facility staff also failed to handle and transport contaminated linens in a manner to prevent contamination and the potential spread of infection for 1 of 4 units. The facility reported a census of 76 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility policy review, the facility failed to ensure a lap belt device, that may restrain a resident's movement, was assessed for safe use upon initiation and periodically following implementation for 1 of 4 residents reviewed for assessment and intervention. The facility reported a census of 76 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) evaluation as required for 1 of 3 reviewed (Resident #83). The facility reported a census of 76 residents.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to ensure a resident was properly positioned and placed in an upright position in order to facilitate consumption of beverages and food and to reduce the risk of choking and aspiration during 1 of 2 mealtime observations. (Resident #31) The facility reported a census of 76 residents.

Inspectors wroteBased on observation, record review, manufacturer's instructions for use, resident representative and staff interview, and policy review the facility staff failed to administer medications and follow the doctor's order for one of six residents reviewed for medication administration (Resident #31). Facility staff gave morphine (an opioid pain medication) instead of lorazepam (an antianxiety medication), administered insulin to the wrong resident, and failed to administer insulin according to manufacturers' instructions for use for 1 for 2 residents reviewed for insulin use (Resident #5) The facility reported a census of 76 residents.

Inspectors wroteBased on observation, policy review, and staff interviews, the facility failed to date opened insulin for 1 of 2 medication carts inspected. The facility reported a census of 76 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure resident preferences for end of life treatments were followed as indicated on their Iowa Physician Orders for Scope of Treatment (IPOST). for 1 of 1 resident reviewed for advance directives (Resident #2). The facility reported a census of 79 residents.

Inspectors wroteBased on resident record review, facility record review and staff interviews, the facility failed to submit the Minimum Data Set (MDS) in a timely manner for 2 of 3 residents reviewed (Resident #28 & #65). The facility reported a census of 70 residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to code an anticoagulant drug accurately on the Minimum Data Set (MDS) for 1 of 4 residents reviewed (Resident #17). The facility reported a census of 70 residents.

Inspectors wroteBased on record review, observation, and staff interviews and policy the facility failed to update Care Plans for 3 of 18 residents reviewed (#R17, R54, R195) did not include pertinent medications or side effects, pressure ulcer and transfer technique. The facility reported a census of 70 residents. Findings Include: 1. The Quarterly, Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed a Brief Interview for Mental Status (BIMS) assessment scored 15 out of 15 indicating cognitive intact. Diagnosis included hypertension, peripheral vascular disease, mood disorder diagnoses included, non-Alzheimer's dementia, anxiety disorder. The MDS coded that antipsychotic medications were given on a routine basis. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to follow Enhanced Barrier Protection (EBP) practices for residents with an indwelling medical device and an open pressure injury for 2 of 2 residents reviewed for infection control (Residents #77 and #195). The facility reported a census of 70.

Inspectors wroteBased on observation, clinical record review, staff interview, and facility policy review, the facility failed to ensure the safety for 1 of 5 residents (Resident #2) reviewed. This failure caused harm when Resident #2 was improperly transferred and needed to be lowered to the floor. This transfer resulted in a ligament injury. The facility reported a census of 72 residents.

Inspectors wroteBased on direct observation, clinical record review, staff interviews, family interviews, and policy review, the facility failed to provide sufficient amount of properly trained staff to implement care plan interventions for 1 of 1 residents with self-injurious behavior. (Resident#37). The facility staff also failed to intervene when the resident displayed behaviors. This resulted in harm to the resident in the form of three occurrences of cellulitis and loss of the distal portion of the left index finger - the tip of the left index finger to the first finger joint. She was placed on antibiotics for the treatment of the cellulitis. The facility reported a census of 75.

Inspectors wroteBased on observation, interview, and facility policy the staff failed to perform hand hygiene to prevent the spread of possible food borne illness for one of one meal observation. The facility reported a census of 75 residents.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to place a barrier prior to performing blood glucose monitoring for 3 of 3 residents reviewed (Residents #13, #26, #55), additionally the facility failed to have a sharp container when needed by staff for 3 of 3 residents (Residents #13, #26, #55), and the facility failed to properly locate the accu monitor while being cleansed by disinfecting wipe while using the same monitor for 3 of 3 residents (Residents #13, #26, #55). The facility also failed to follow infection control during dining service. The facility reported a census of 75 residents.

Inspectors wroteBased on observation, clinical record review, resident interview, staff interviews and facility policy review, the facility failed to follow physician orders for 3 of 18 residents reviewed (Residents #20, #30 & #67). Resident #20 consistently received medications significantly past the ordered time, Resident #30 was administered a treatment that had been previously discontinued, and the facility failed to obtain ordered daily weights for Resident #67. The facility reported a census of 75.

Inspectors wroteBased on observation, resident interview, staff interview, record review and policy review, the facility failed to provide necessary services to maintain grooming for nail care for 1 of 1 residents (Resident #67) reviewed for Activities of Daily Living (ADL). The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record, provider interview, and policy review, the facility failed to document a reason for declining a Gradual Dose Reduction (GDR) for 1 of 5 residents reviewed (Resident #42). The facility reported a census of 75.

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to protect medical records in a confidential and secure manner for 2 of 19 (Resident #41, #26) residents reviewed for medication administration. The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview and a lift device user's manual review, the facility failed to ensure staff maintained a safe and secure environment for 2 of 3 residents reviewed (Resident #3 and #5) which resulted in falls. The facility identified a census of 75 residents.