Valley Vista Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure that four out of five sampled residents (Residents 2, 10, 19 and 49) were free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medications when: 1. For Resident 10, the facility did not implement resident specific non-pharmacological interventions (NPIs, behavioral treatments that do not involve medications) for the use of clonazepam (medication used to treat anxiety), mirtazapine (medication used to treat depression), risperidone (antipsychotic medication that balances certain chemicals in the brain to help a person feel calmer and think clearly), buspirone (medication used to treat anxiety) and sertraline (medication used to treat depression).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmacy services in accordance with accepted standards of practice when:1. Random controlled medication (medications with a high abuse potential) use audit for five of six sampled residents (Residents 3, 7, 25, 40 and 55) showed that medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. This failure had the potential for diversion (unlawful distribution or use), mismanagement of controlled medications, and the potential to not meet the needs of the residents in the facility. 2. Medications were not available for two of five sampled residents (Residents 2 and 42) when they were scheduled to be administered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater, when observation of 42 opportunities during medication administration resulted in five errors. The calculated medication error rate was 11.9%.This failure resulted in1. Placing Resident 29 at risk of not breaking down and absorbing nutrients from food when Licensed Nurse (LN) 1 crushed and administered pancrelipase (digestive enzymes used to break down food during digestion) Delayed Release (DR, designed to release medication slowly over a period). Placing Resident 29 at risk of inadequate pain relief when LN 1 crushed and administered gabapentin (medication used for pain).2. Placing Resident 42 at risk of high blood pressure when LN 31 did not administer hydralazine (a medication used to treat high blood pressure).3. [...]

Inspectors wroteBased on interview and record review the facility failed to identify and develop an effective quality assessment and performance improvement plan (QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) in the following areas related to:1) cross reference F 755- Pharmacy services- the facility failed to ensure the control drug record (CDR) matches the medication administration record (MAR) of controlled drugs of the residents for five out of six residents reviewed. 2) cross reference F 677- ADL care provided for dependent residents- the facility failed to provide nail care assistance for two out of 17 residents reviewed. These failures had the potential to affect the resident's health and condition. On 9/11/25 at 3:45 P.M., a QAPI meeting with the Director of Nursing (DON) and the Administrator (ADM) was conducted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards of practice when an air vent blew out dust balls during meals in the dining room. This deficient practice had the potential to contaminate residents' food and affect the residents' respiratory status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an alternative call light system to one of 17 sampled residents (Resident 68). This failure had the potential for Resident 68 to experience a delay in care.

Inspectors wroteBased on interview and record reviews, the facility failed to provide a written notice and duration of bed hold for one of three residents (Resident 65) reviewed for bed hold notice. This failure had the potential for the resident and/or resident's representative to not have information regarding bed hold rights. Per the facility's admission Record, Resident 65 was admitted to the facility on [DATE] with diagnoses which included, chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood). A review of the progress notes dated, 6/25/25 indicated, Resident 65 was transferred to the acute hospital due to wounds on his buttocks. A review of Resident 65's medical record indicated, there was no documentation to confirm Resident 65 was notified of the bed hold when Resident 65 was transferred to the acute hospital. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed for 2 of 17 residents (Residents 2 and 19) reviewed for baseline care plans. This failure had the potential for Resident 2 and Resident 19 to not receive appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 17 residents (Resident 10 and Resident 49), who needed to carry out activities of daily living (ADL- self-care activities such as grooming, bathing, and toileting), received assistance with nail care (cleaning, trimming and/or filing of nails). As a result of this deficient practice, residents' fingernails were long and had the potential for skin injury and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure intake and output (I & O- the measurement of the fluids that enter the body and the fluids that leave the body) was documented and monitored for one of 17 sampled residents (Resident 68). This failure placed Resident 68 at risk for edema (swelling), retaining fluid in the lungs or dehydration (loss of body fluids).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Restorative Nursing Assistant (RNA- a program to restore abilities or maintain function) program intervention with a hand splint (a device used to immobilize and keep the hand in one position) for one of 17 sampled residents (Resident 68). This failure had the potential for Resident 68 to experience further hand stiffening and/or skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision with feeding in one of 17 residents (Resident 43) reviewed for activities of daily living (ADL- self-care activities such as feeding, grooming, bathing, and toileting) assistance. This failure had the potential to affect Resident 43's health and well being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide urology (specialty which deals with diseases of kidneys and bladder) follow up for one of two residents (Resident 4) reviewed for urinary catheter. This failure had the potential for Resident 4 to have a recurrent urinary tract infection (UTI-an infection affecting the kidneys, bladder or urethra) and other complications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nutrition interventions were implemented for one of 17 sampled residents (Resident 68). This failure had the potential to result in further weight loss and/or compromise Resident 68's health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for oxygen was placed for one of three residents (Resident 2) reviewed .This failure had the potential to affect Resident 2's respiratory condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the one of 17 residents (Resident 6) reviewed for food palatability was served meals that were palatable. As a result, Resident 6 refused his meals and was at risk for weight loss. Cross reference F805Findings:Resident 4 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD- when stomach contents flow back up into the tube that connects the mouth to the stomach) according to the facility's admission Record. During an observation and interview on 9/8/25 at 8:24 A.M. with Resident 4, Resident 4 stated he was on a puree diet, but the food did not taste good. Resident 4 stated the puree he received was gritty. During an interview on 9/10/25 at 9:17 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure recipes were followed during the preparation of pureed foods. This failure placed the resident at risk for choking and/or aspiration (inhaling food into the lungs) and compromised the flavor and texture of the foods.

Inspectors wroteBased on observation, interview and review of the analysis of client accommodations , the facility failed to meet the required minimum square footage requirements of at least 80 square feet per resident (sq/ft/resident) in three resident rooms (6,8,and 11) This failure had the potential to impact resident care and quality of life. A record review was conducted from 9/8/25 through 9/11/25. The following resident rooms contained less than 80 square feet for each resident. Room Number Room Size6 accommodated 3 residents 216 (72 sq ft/ resident)8 accommodated 3 residents 216 (72 sq ft/ resident)11 accommodated 2 residents 138 (69 sq ft /resident) Additionally, observations were conducted. There were no observed quality of care , or quality of life concerns that negatively affected the residents residing in the identified rooms during the recertification survey visit. [...]

Inspectors wroteBased on observation, interview and record reviews the facility failed to develop and implement a comprehensive person focused care plan for one of one resident (Resident 1) related to Oxygen use. This failure had the potential to affect Resident 1 ' s health condition and possible decline. Findings. Per the undated admission Record , Resident 1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Atrial Fibrillation (irregular heart rhythm). On 6/10/25 at 11 A.M., an observation and interview with Resident 1 was conducted. Resident 1 was alert, verbal, and receiving oxygen through nasa cannula (NC- a device that delivers oxygen through the nose) at 2 liters per minute while sitting up in her wheelchair in her room. Resident 1 stated, she used the oxygen all the time because she cannot breathe without the oxygen. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were safe from abuse when a one to one (1:1) supervision was not consistently followed as recommended for one resident (Resident 1), who had a history of abusive behavior. As a result, Resident 1 hit another resident (Resident 2). In addition, this failure placed all residents at the facility at risk of being harmed by Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure proper safe and sanitary food practices, storage, and sanitation requirements were met when: 1. Expired foods in the refrigerator were not discarded, 2. Two blenders had residual food debris encrusted on them, and 3. A cabinet for equipment had a missing door, and the inside surface had a buildup of dust, dirt and black substances stuck on all sides. These failures had the potential to result in harmful bacteria growth and cross contamination, which would cause food borne illness to 51 vulnerable residents who receive food from the kitchen and who were medically compromised.

Inspectors wroteBased on observation, interview and record review, the facility failed to allow personal items to be posted on the walls of their rooms for two of two residents screened for personal property (Residents 6 and 16). This failure had the potential to negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications according to accepted professional practice for one of 52 residents screened (Resident 41). This failure had the potential for Resident to suffer harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services and treatment for mental health needs for one of 52 residents screened (Resident 50). This failure had the potential for the mental health needs of Resident 50 to be unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.45%. Two medication errors were observed, a total of 31 opportunities, during the medication administration process for two of five randomly observed residents (Residents 2 and 24). As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview, and review of the Analysis of Client Accommodations, the facility failed to meet the required minimum square footage requirements of at least 80 square feet per resident (sq ft/resident) in three resident bedrooms (6, 8, and 11). This failure had the potential to impact resident care and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired oral medications and topical creams were removed from the current medication supplies. In addition, nasal sprays, eye drops, and pain patches were commingled with the current medication supplies readily available for residents' use. Also, the medication room temperature was not consistently monitored as required. These failures had the potential for unsafe storage of medications thereby losing the efficacy of the medications.

Inspectors wroteBased on observation, interview, and review of the Analysis of Client Accommodations, the facility failed to meet the required minimum square footage requirements of at least 80 square feet per resident (sq ft/resident) in 3 resident bedrooms (6, 8, and 11). This failure had the potential to impact resident care and quality of life.