Valley View Health Care Center, INC

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Rights Deficiencies

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Keep all essential equipment working safely.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

A complaint survey, prompted by #CO39084, #CO39087, #CO39207, #CO39357, Incident #39109, Incident #39155, Incident #39160, Incident #39183, Incident #39184, Incident #39244 and Incident #39360 was conducted on 2/25/25 to 2/26/25. Six deficiencies were cited. Based on observations and interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment in seven of 26 resident rooms and damaged areas in one of two resident halls out of two units.Specifically, the facility failed to:-Ensure blinds were intact in seven resident rooms; and, -Ensure the heating vents were intact and not falling off the heating units.Findings include:I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 2/26/25 at 5:26 p.m. It read in pertinent p.. Based on record review and interviews, the facility failed to ensure five (#1,#7, #4, #10 and #3) of 15 residents reviewed for abuse were kept free from abuse out of 17 sample residents. Specifically, the facility failed to:-Protect Resident #1 from physical abuse by Resident #6 and Resident #2;-Protect Resident #7 from physical abuse by Resident #2;-Protect Resident #4 from physical abuse by Resident #5;-Protect Resident #10 from physical abuse by Resident #11; and,-Protect Resident #3 from verbal abuse by a staff member.Findings include:I. Facility policy and pr.. Based on record review and interviews, the facility failed to ensure one (#3) of three residents at risk for elopement out of 17 sample residents received adequate supervision and were kept free from elopement.Specifically, the facility failed to provide Resident #3 with the supervision necessary to prevent elopement. The facility' s failures created a situation for the likelihood of serious harm to residents' health and safety if not immediately corrected.The facility was a totally secure building specializing in serving residents with severe mental illness, dementia and behavioral he.. Based on record review and interviews, the facility failed to establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident' s personal funds entrusted to the facility on the resident' s behalf for one (#8) of four residents reviewed for personal funds out of 17 sample residents.Specifically, the facility failed to provide Resident #8 a copy of her personal funds statement on at least a quarterly basis.Findings include:I. Resident statusResident #8, age 72, was admitted on 10/31/18. Accordin.. Based on record review and interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate.Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital.Findings include:I. Record reviewA request was made to the nursing home administrator (NHA) on 2/26/25 a.. Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment that included all resources, education, staff competencies and facility based risk assessments for a facility that was a totally secured locked facility for residents with mental illness and dementia diagnosis. Cross-reference F689: failure to prevent a resident from elopin..

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This facility is one story, Type V (111), with slab on grade construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as fully sprink.. STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was eviden.. STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected areas in accordance with Life Safety Section 19.3.2.5. This deficient practice could affect all residents and staff in the main smoke compartment including the kitchen should there be smoke and heat transfer between the hazardous area and other portions of the building. This.. STANDARD is not met as evidenced by: Based on record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This deficient practice could affect all residents, staff and visitors should the portable fire extinguishers fail to operate effectively due to non-code compliant maintenance. This was evidence by the following.Records that fire extinguishers in the kitchen and smokin.. STANDARD is not met as evidenced by: During the tour of the facility with the staff, it was determined that the facility failed to provide proper operation of the Kitchen Hood System as required by NFPA 96, (Chapter 8, and Section 8.2.3.1). This deficient practice could affect all residents, and staff should a fire occur. Record review indicated the kitchen hood exhaust fan does not continue to operate after activation of extinguishing system.NFPA 9.. STANDARD is not met as evidenced by: It was determined by record review and staff interview during the course of the survey, the facility failed to perform and document the exercising of all fire and smoke damper at least every four years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This deficient practice could affect all residents, staff and visitors if the .. STANDARD is not met based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:1. No documentation was available during record review of the facility required testing o.. STANDARD not met: Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the trans-filling of oxygen from one cylinder to another in accordance with NFPA 99 - Health Care Facilities, 11.5.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. The following evidenced this:The oxygen trans-filling room not mechanically ventilated corr..

A recertification survey with complaint #CO35780, #CO36011 and Incident #35111 was completed on 5/13/24 to 5/15/24. Six deficiences were cited. An Emergency Preparedness survey was conducted from 5/13/24 to 5/15/24. No deficiencies were cited. Based on interviews and observations, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the main kitchen.Specifically the facility failed to:-Ensure the kitchen' s oven was maintained to function properly;-Ensure two of six burners were functioning properly; and, -Ensure the kitchen oven door was repaired to ensure the oven maintained consistent and appropriate cooking temperatures for cooked f.. Based on interviews and record review, the facility failed to ensure one (#10) of fifteen residents reviewed for choices out of 32 sample residents remained free of resident right restrictions in order to promote and facilitate resident self- determination.Specifically the facility failed to ensure Resident #10 received baths consistently according to his choice of frequency and bathing preference. Findings include:I. Facility policy and procedureThe Dignity policy and procedu.. Based on observations and interviews, the facility failed to provide a meal service for residents in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for residents served in two of two dining rooms. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served and seated in the dining room. I. Facilit.. Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen.Specifically, the facility failed to:-Ensure the walk-in refrigerator maintained a safe operating temperature of 41 degrees Fahrenheit (F) or below to prevent food from spoiling; and, -Ensure all damaged tiles were repaired to ensure all surfaces in the kitchen were cleanable.Findings include:I. Ensur.. Based on observations, record review and interviews, the facility failed to ensure one (#23) of five residents reviewed for ancillary services out of 33 sample residents received routine dental care and 24-hour emergency dental care. Specifically, the facility failed to refer Resident #23 to the dentist to obtain dentures timely.Findings include:I. Facility policyThe Ancillary Service policy and procedure, dated 11/4/13, was provided by the nursing home administ.. Based on record review and interviews, the facility failed to incorporate the recommendations from the PASRR (preadmission screening and resident review) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#2) of five residents out of 32 sample residents. Specifically, the facility failed to:-Take steps to ensure services were provided as recommend in Resident #2 ' s PASRR Level II report; and, -Ensure t..