Valley Of The Moon Post Acute

Based on observation, interview, and record review, the facility failed to store and prepare food according to professional standards for food safety for a facility census of 27 residents when:A large dented can was stored in the ready for use dry storage area,Expired food items were stored in the ready for use dry storage area,An opened food package was stored without any labeling in the ready for use dry storage area, and;Scratched and peeling plastic cutting boards were in use in the food preparation area.These failures created the potential for food contamination and food borne illness for a vulnerable resident population. Cross reference F908. 1. During a concurrent observation and interview on 7/13/26 at 9:15 a.m. with the Dietary Manager (DM), a large dented can of pinto beans was found in the ready for use area. The DM stated the can should have been removed from stock.2. During a concurrent observation and interview on 7/13/26 at 9:20 a.m. with DM, two opened containers of cake icing with expiration dates of 5/6/26, and a bag of whole wheat noodles with an expiration date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F689 - Free of Accident Hazards/Supervision/DevicesBased on interview and record review, the facility failed to ensure a timely post-fall risk evaluation assessment was completed following a resident fall, for one of three sampled residents, (Resident 32), reviewed for falls.This failure resulted in a missed opportunity to identify and address additional fall risk factors before Resident 32 experienced a second fall in the facility and placed him at an increased risk for potential injury. Findings:A record review of Resident 32's admission record (facility demographic) indicated, Resident 32 was admitted to the facility on [DATE], with initial diagnoses including but not limited to a heart attack (when a blocked artery stops blood and oxygen from reaching a section of the heart) and dementia (a progressive state of decline in mental abilities).A record review of a change in condition assessment dated [DATE], indicated Resident 32 experienced a fall in the facility.A record review of a change in condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident right to know about, and had access to, the contact information for the Ombudsman (State Patient/Resident advocacy services) and California Department of Public Health (CDPH) and Federal and State Survey results. This failure had the potential for not allowing Residents or their family members to exercise their right to know contact advocates about their concerns regarding the care they received in the facility and how to view the results of the facility surveys and the plans of correction (A document from the facility that would state how to correct any deficiencies or findings, and to keep them from happening again.) prepared by the facility in response to a complaint investigation or recertification survey. Findings: (Cross Reference F575, F577) During an observation on 10/7/24, at 2:30 p.m., the bulletin boards across from the nursing station to the right of room [ROOM NUMBER] were observed to be blocked by one of two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents knew about, and had access to, the contact information for the Ombudsman (State Patient/Resident advocate services) and California Department of Public Health (CDPH) and Federal and State Survey results. This had the potential for not allowing Residents or their family members to exercise their right to know contact advocates about their concerns regarding the care they received in the facility and how to view the results of the facility surveys and the plans of correction. Findings: (Cross Reference F550, F575) During an observation on 10/7/24, at 2:30 p.m., the bulletin boards across from the nursing station to the right of room [ROOM NUMBER] were observed to be blocked by one of two medicine carts. During an observation on 10/7/24, at 4:15 p.m., the activity / dining room, and the staff break room was observed to not have a poster that indicated how to contact the Ombudsman, CDPH, or where to find the facility survey…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and clinical record review, the facility failed to maintain a portable oxygen tank inventory and properly anticipate emergent respiratory care equipment needs for six Sampled Residents (Resident 4, Resident 2, Resident 1, Resident 13, Resident 80, Resident 6), and 2 Unsampled Resident (Resident 5, Resident 9) who received oxygen therapy. The facility's inability to ensure Resident's daily and emergent oxygen needs had the potential for Respiratory Distress (shortness of breath, difficulty breathing, and possible respiratory failure), Hypoxemia (oxygen deprivation) and potential for death, during a facility evacuation that required transport of residents to county shelters or private homes. Findings: During an observation and interview, on 10/7/24 at 2:45 p.m., Sampled Resident 4 was observed in her bed. The head of her bed was at 45 degrees. Oxygen was being delivered via nasal cannula (through the nose) connected to a wall mounted medical gas delivery system at 2 Liters per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility: 1) Failed to ensure Registered Nurses (RNs) had accurate, verified competencies (verification of essential job functions; skills/ability required to perform safe nursing care) in their employee files when 2 of 2 sampled Registered Nurses (RN B and RN C) did not have documented, complete PICC line (peripherally inserted central catheter) competencies per facility policy, and 2) Failed to ensure Licensed Vocational Nurse L (LVN L) had accurate competencies in his employee file when LVN L's employee file indicated he had PICC line competencies, but LVN's are not legally nor professionally qualified to care for PICC lines. These deficiencies caused potential for unsafe nursing practice and potentially placed PICC residents at risk of harm. (A PICC line is an intravenous catheter [also called a central line] that is inserted into a vein in the arm, which is advanced toward the heart until the tip rests in the vein near the heart. A PICC is used to administer medication directly into the large vein near the heart). Findings: Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the safety of one sampled resident (Sampled Resident 1), when medication that was ordered to be administered on an empty stomach was administered at the same time as two medication that were ordered to be administered with food. This medication administration was the result of not following the physician's order and had the potential to result in medication not being absorbed properly and the risk of Sampled Resident 1 to experience side effects that included gastric upset, nausea and gastric reflux. Finding: During an observation on 10/8/24, at 8:51 a.m., Licensed Vocational Nurse K administered Gabapentin (Medication used to treat pain), Omeprazole DR (Medication used to decrease the amount of acid produced by the stomach.) and Metformin (Medication used to treat diabetes) to Sampled Resident 1. During an interview and record review on 10/8/24 at 8:55 a.m., Licensed Vocational Nurse K stated breakfast was served between 7:30 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, and record review, the facility failed to provide the services of a Director of Nursing (DON) on a full time basis for the last thee months. This failure prevented the oversight of a professional Registered Nurse (RN) in the management and direction of all aspects of the nursing services department that could adversely impact the care and treatment of residents residing in the facility. Findings: During an interview on 7/24/23, at 11:52 AM, the Administrator stated the facility did not have a Director of Nursing. During an interview on 7/27/23, at 3:15, the Director of Staff Development (DSD) stated the facility did not have a full time DON since early 4/2023. During a follow-up interview on 7/28/23, at 2:29 PM, the Administrator stated he had been the Administrator since 1/2023 and the facility had been without a DON since 4/2023. The Administrator stated the facility already had a corrective action plan and prospects for the position of DON but wanted to ensure they hired a candidate who will best fit the position. A review of the facility document titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility did not create a care plan for one of two residents (Resident 11) who was on supplemental oxygen (O2) for 7 months. This failure could result to oxygen toxicity or oxygen poisoning (lung damage that happens from breathing in too much extra [supplemental] oxygen), which can cause coughing, trouble breathing, and in severe cases it could potentially cause death. Findings: During the initial tour of the facility on 07/25/23 at 11:36 AM, Resident 11 was observed seated in her wheelchair at the bedside. Resident 11 was on O2 via a nasal cannula (a thin tube which delivers oxygen into the nose) and was receiving the O2 at two Liters (unit of volume) Per Minute (2 LPM). During a follow-up visit on 07/27/23 at 11:19 AM, Resident 11 was on O2 via nasal cannula at 2 LPM. During a review of records on 07/27/23 at 11:54 AM, Resident 11's face sheet (one-page summary of important information about a patient including patient identification, past medical history, medications, allergies, insurance status, or other pertinent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and a review of records, it was determined that the facility failed to meet the pharmaceutical needs of its residents by not having proper procedures in place to ensure the accurate administration of all drugs. Specifically, during the administration of an insulin injection to Resident 25, it was observed that the injection site was not rotated, and the same site was used multiple times by several different nurses. This could potentially lead to an adverse reaction such as lipodystrophy (a disorder that affects how the body accumulates and stores fat). Findings: A review of the Lispro insulin manufacture's insert indicated that Lispro was a type of medicine that helps people with diabetes keep their blood sugar at a healthy level. Lispro subcutaneous administration (given as a shot under the skin) should be given in different places on the body like the stomach, thigh, upper arm, or buttocks. It's important to rotate (change where the shot is given each time) the injection site so that the skin stays healthy. This is because long-term use of Lispro insulin can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, it was discovered that the facility pharmacist failed to report irregularities, and the facility itself did not take appropriate action in response to these irregularities. The facility pharmacist failed to identify the lack of insulin site rotation for Resident 25, which resulted in the resident at risk for lipodystrophy due to repeated injection at the same site. Lipodystrophy is a disorder that affects how the body accumulates and stores fat. Findings: During a review on 7/24/23 of Resident 25's Medication Administration Record (MAR) and following an observation and interview with LVN A, a concerning pattern was identified. Multiple different nurses had failed to rotate the insulin administration sites properly, which raised concerns about the potential development of complications. The number of instances of non-rotated injection sites were as follows: 6/7/2023: - Bedtime dose administered insulin in the lower upper quadrant of the abdomen. - Next dose administered insulin in the lower upper quadrant of the abdomen. 6/9/2023: - Afternoon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-nine opportunities, resulting in an error rate of 10%. Findings: 1. A review of the Lispro insulin manufacturer's insert indicated that Lispro is a type of medicine that helps people with diabetes keep their blood sugar at a healthy level. Lispro subcutaneous administration (given as a shot under the skin) should be given in different places on the body like the stomach, thigh, upper arm, or buttocks. It's important to rotate (change where the shot is given each time) the injection site so that the skin stays healthy. This is because long-term use of Lispro insulin can cause lipodystrophy at the site of repeated insulin injections. Lipodystrophy is a disorder that affects how the body accumulates and stores fat. A review of Resident 25's electronic record on 7/24/23, it was noted that the physician had ordered a sliding scale (a way to adjust the amount of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.