Valley View Villa

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

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

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Quality of Life and Care Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the kitchen cooking appliance locations in accordance with National Fire Protection Association (NFPA) Standard 96.1. Missing a Semi-Annual Hood Cleaning Inspection Report 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on January 14th, 2025 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type V (000) construction. This structure has a partial basement for support services only and no resident access. The facility is licensed for 120 beds and the census on the date of the survey was 37. The facility was constructed in 1975. The facility is fully protected by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry fire sprinkler systems. The anti-freeze loop protects the exterior canopy and exterior overhangs. The facility is classified as fully sprinklered.The results of this survey were discussed with the Director of Maintenance and the Facility Administrator during the exit conference conducted on January 14th, 2025.

A recertification survey with complaint #CO37811 was completed on 12/16/24 to 12/19/24. One deficiency was cited. An Emergency Preparedness survey was conducted from 12/16/24 to 12/19/24. No deficiencies were cited. Based on observations and interviews, 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.Specifically, the facility failed to ensure housekeeping staff followed appropriate cleaning practices by treating each side of the room as a separate patient zone, cleaning all high touch surfaces and cleaning items in the rooms from cleanest to dirtiest.Findings include:I. Professional referenceAccording to The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures (3/19/24), retrieved on 12/23/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html, "Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. "Change cleaning cloths between each patient zone (use a new cleaning cloth for each patient bed),"High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility."Common high-touch surfaces include: bedrails; IV (intravenous) poles; sink handles..

During the survey, it was determined that the facility failed to maintain oxygen equipment and operating procedures according to NFPA 101, NFPA 99 (2012) and NFPA 55 (2010). This was evidenced by the following: 1. Full and empty oxygen containers were not separated.2. Oxygen storage room ventilation was poor.3. Out of service electrical components were not removed or covered in oxygen storage room.NFPA 99 11.6.5.1 Storage shall be planned so that .. During the survey, it was determined that the facility failed to meet the corridor requirements in accordance with NFPA 101, NFPA 80 (2010) and NFPA 105 (2010). This was evidenced by:1. Missing annual rated door inspection/testing/maintenance report.2. Metal trim (astragal) on the non-rated corridor doors between the dining room and front lobby prevents the doors from easily opening in the direction of egress. NFPA 101 7.2.1.15.2 Fi.. During the survey, it was determined that the facility failed to meet the egress requirements in accordance with NFPA 101 (2012). This was evidenced by:1. Sidewalk is uneven from the west door egress path and from the interior courtyard.NFPA 101 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled .. During the survey, it was determined that the facility failed to meet the fire and smoke resistive construction requirements in accordance with NFPA 101. This was evidenced by:1. Accounts payable office has damage to the drywall over closet.2. Boiler room has damage to drywall materials in several areas.NFPA 101 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found a.. During the survey, it was determined that the facility failed to meet the operational requirements in accordance with NFPA 101, NFPA 54 (2012) and NFPA 96 (2011). This was evidenced by:1. Wheeled, gas fueled kitchen appliance restraint tethers were not attached or installed.NFPA 54 (2012) 9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the co.. During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 (2012), NFPA 80 (2010) and NFPA 90A (2012). This was evidenced by:1. Missing 4-year fire damper inspection/testing/maintenance report.NFPA 101 Referenced Publications 2.2 NFPA Publications NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition.-NFPA 80 19.4 Periodic Inspection and Testing 19.4.1.1 The t.. During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, NFPA 25 (2011) and NFPA 13 (2010). This was evidenced by:1. Missing spare fire sprinkler inventory list in riser room.2. Multiple fire sprinklers were loaded, painted or corroded throughout the building.3. Freezer was protected with a dry fire sprinkler manufactured in 2009.NFPA 13 6.2.9.7 A list of the sprinklers installed in the prop.. During the survey, it was determined the facility failed to maintain electrical and gas equipment with NFPA 101, NFPA 54 (2012) and NFPA 70 (2011) based on the following:1. Gas dryer orifice size was rated for 0-2,000 feet in elevation. Site elevation is over 4,000 feet.NFPA 54 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall .. INITIAL COMENTS (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 survey was conducted on September 13, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type V (000) ..

A licensure survey was completed on 8/15/23 to 8/17/23. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#13) of two residents reviewed for nutrition out of 18 sample residents to maintain acceptable parameters of nutritional status.Specifically the facility failed to implement appropriate nutrition interventions when the resident sustained a severe, 13% weight loss in three months. Findings include: I. Facility policy and procedure The Resident at Risk (RAR) policy, revised 12/16/21, was provided by the nursing home administrator (NHA) on 8/17/23 at approximately 2:00 p.m. The policy read in pertinent part: "The facility conducts a weekly resident at risk meeting to review residents identified with problems or concerns related to their nutritional status or have an identified risk factor that may lead to nutrition and hydration issues. The Review List includes but is not limited to the following. Readmission after a temporary stay at the hospital if there has been a change that affects the resident' s nutritional status for a minimum of one week. Residents with significant weight change: 5% in 30 days, 7.5% in 90 days, 10% in 180 days. "Documentation recorded in the medical record may be completed by a designated committee member and may include but is not limited to:-Acknowledgement of any significant change, if applicable-Progression/digression of interventions-Change to interventions-Updating the care plan. Interventions should be specific, individualized and dated.The designee for Food and Nutrition Services may complete the following before the meeting:-Update food preference-Follow up on prior interventions to determine the effectiveness-Discuss resident dining/food concerns with nursing staff-Speak with family members-Review medical information, meal consumptions, nursing notes, labs. The designee for Nursing may complete the following before the meeting:-Review current labs-Review snack/supplement consumption-Ensure the physician, resident and/or responsible party have be..