Valley Rehabilitation And Healthcare Center, The

Based on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for one (#1) of two residents out of seven sample residents.Specifically, the facility failed to ensure medical records were provided timely upon request to Resident #1's representative.Findings include:I. Facility policy and procedure The Release of Information policy, revised November 2009, was provided by the clinical regional director on 9/10/25 at 3:21 p.m. The policy read in pertinent part, The resident may initiate a request to release such information contained in his or her records and charts to anyone he or she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative. A resident may obtain photocopies of his or her records by providing the facility with at least a 48 hour advance notice of such request. II. Resident representative interviewResident #1's representative was interviewed on 9/10/25 at 2:09 p.m. The representative said she requested Resident #1's medical records from…

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 record review and interviews, the facility failed to ensure care plans were revised and appropriate for three (#1 and #3) of four residents reviewed for comprehensive care plans out of seven sample residents.Specifically, the facility failed to:-Ensure Resident #1's fall care plan was revised to include new interventions if needed to assist in the prevention of falls for 11 out the resident's 13 falls between 1/17/25 and 6/27/25; and,-Ensure Resident #3's care plan was revised to include new interventions if needed after the resident fell on 7/27/25.Findings include:I. Facility policy and procedure The Falls-Clinical Protocol policy, revised March 2018, was provided by the nursing home administrator (NHA) on 9/10/25 at 8:01 p.m. via email. According to the fall policy, the staff and the physician would identify pertinent interventions to try to prevent falls and to address the risks of clinical significant consequences of the falls. The policy identified the staff would try various relevant…

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, 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 kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination; and, -Ensure safe holding temperatures for food items were maintained. Findings include: I. Inappropriate handling of ready-to-eat foods A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 7/1/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. B. Facility policy The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, revised 11/2022, was provided by the nursing home administrator (NHA) on 6/26/24 at 2:20 p.m. It read in pertinent part, Gloves are…

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 interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled on three of five units. Specifically, the facility failed to ensure residents' topical medications were stored and locked in appropriate medication carts or medication storage rooms that were accessed only by authorized licensed personnel. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy and procedure, reviewed February 2023, was provided by the nursing home administrator (NHA) on 6/26/24 at 2:20 p.m. It read in pertinent part, Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise available to others. Medications are stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer or other…

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 record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on four of five units. Specifically, the facility failed to: -Ensure residents' rooms were cleaned in a sanitary manner; -Ensure residents' personal care items were labeled and stored in a sanitary manner; and, -Ensure a urinary catheter was maintained in a sanitary manner. Findings include: I. Housekeeping failures A. Professional reference The Centers for Disease Control and Prevention (CDC), Environment Cleaning Procedures (5/4/23), was retrieved on 7/1/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Clean patient areas (patient zones) before patient toilets. B. Manufacturer's recommendations According to the Lysol Power and Fresh Multi-Surface Cleaner guidelines, undated,…

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, record review, and interviews the facility failed to ensure all drugs and biologicals were properly stored in one of one medication storage refrigerators. Specifically, the facility failed to ensure proper storage temperatures for medications and vaccines. Findings include: I. Facility policy and procedure The Medication policy, no date of inception or revision, provided by the corporate nurse (CN) on 2/26/2020 at 5:17 p.m. read, medications requiring refrigeration shall be stored in the medication room refrigerator. The refrigerator would be maintained according to the requirements of the Colorado Board of Pharmacy. II. Observations The facility medication storage refrigerator was inspected with the medication administration aide (MAA) on 2/26/2020 at 3:45 p.m. The internal temperature of the refrigerator was observed to be 32 degrees fahrenheit, which was confirmed with the staff member. She was unaware of the correct storage temperatures and said she would have to find out. She said the night shift staff were responsible for checking storage temperatures.…

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 observations, record review, and interviews, the facility failed to ensure one (#24) of three residents reviewed for bathing and grooming received the necessary assistance with activities of daily living (ADLs) of 26 sample residents. Specifically, the facility failed to ensure Resident #24 received timely assistance with eye and facial cleanliness, adequate fingernail and oral care, and ensure his clothing was clean. Findings include: I. Facility policy and procedure The Activities of Daily Living policy and procedure, undated, was provided by the nursing home administrator on 2/27/2020 at 2:00 p.m. It documented a program of ADLs was provided to residents to prevent disability and return residents to a maximum level of independence. During hygiene care, residents' self-image was maintained, equipment and instructions for mouth care, shaving, and hair care were provided, and frequent showers or baths were scheduled and assistance was provided when required. II. Resident #24 status Resident #24, age…

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, record review and staff interviews, the facility failed to minimize the risk for foodborne illness in a highly susceptible population in one of one kitchen. Specifically, the facility failed to follow industry standards for proper cleaning and sanitizing of kitchen equipment and utensils and to properly date mark and discard expired foods. Findings include: I. Inadequate sanitizing of equipment of utensils A. Professional references 1. According to the Colorado Retail Food Establishment Rules and Regulations, effective January 1, 2019, p. 73; food contact and non-food contact surfaces shall be clean to sight and touch and kept free of dust, dirt, food residue and other debris. In addition, details for cleaning and sanitizing specific to equipment and chemicals used by the facility included the following: a. Effective cleaning of equipment and utensils shall utilize manual or mechanical means with the use of appropriate detergents and wetting agents (p. 143). b. Equipment food-contact surfaces and utensils should be cleaned and sanitized at the following times…

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 VI. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the 10/24/18 MDS assessment, diagnoses included Alzheimer's disease, psychotic disorder other than schizophrenia, dementia with behavioral disturbance, and unspecified psychosis. The 10/24/18 MDS assessment revealed the resident had short- and long-term memory problems with severely impaired cognitive skills for daily decision making. She had adequate hearing, vision, and unclear speech, and no psychosis behavioral symptoms or rejection of care. She was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The 7/25/18 comprehensive MDS assessment revealed the staff completed her activity preferences, which included listening to music and being around animals such as pets. B. Observations 1/07/19 -At 2:44 p.m. the resident was observed alone in her room in bed. A bingo activity was in progress and she did not attend. -At 5:04 p.m. the resident was observed in her…

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 observations, record review, and staff interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of one medication storage refrigerator. Specifically, the facility failed to ensure vaccines were stored according to practice standards and manufacturer guidelines. Findings include: I. Professional standards According to the Centers for Disease Control and Prevention (CDC) Vaccine Storage and Handling Toolkit ([DATE]), pages 8 - 15, retrieved from https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf on [DATE], included in pertinent part: Failure to store and handle vaccines properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease. Do not store any vaccine in a dormitory style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an ice maker/freezer…

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.