Valley Pines Adult Care

The facility failed to provide adequate supervision for a resident with dementia, resulting in two separate elopement incidents. During these incidents, the resident left the facility unnoticed, once traveling 6.6 miles away and requiring police intervention and a Silver Alert.

The facility failed to provide adequate supervision for Resident #2, resulting in two separate elopement incidents on 01/10/25 and 01/17/25. During these incidents, the resident left the facility and was found on local streets, posing significant safety risks due to proximity to busy highways and varying weather conditions.

The facility failed to ensure that staff members were competency validated to perform licensed health professional support tasks. Specifically, staff were not validated to apply Santyl ointment, an enzymatic wound debriding agent, for one resident.

The facility failed to ensure staff were competency validated to apply an enzymatic wound debridement agent. Specifically, one of three residents reviewed was found to have a Stage I decubitus on the right great toe that required daily treatment by unvalidated staff.

The facility failed to assure referral and follow-up to meet the acute health care needs of residents. Specifically, staff failed to notify the physician of a new wound for Resident #3, failed to coordinate a physician's order for a medication change from Humalog to Novolog, and failed to notify the physician of health or weight changes for other residents.

The facility failed to ensure proper referral and follow-up for the acute health care needs of residents. Specifically, staff failed to coordinate a physician's order for insulin changes, failed to notify physicians of new wounds and health changes, and failed to report weight changes as ordered.

The facility failed to maintain walls, ceilings, and floors in a clean and good repair. Specific issues included rusty floor vents, chipped and peeling paint, and dark brown or blackish stains on walls, door frames, and tub molding in multiple common bathrooms and hallways.