Valley Vue Care Center

Based on record review, manufacturer's guidelines and staff interview, the facility failed to assure residents insulin pen was primed prior to insulin administration preventing a significant medication error for 1 of 1 resident reviewed (Resident #12). The facility reported a census of 32 residents.Findings include:During an ongoing observation on 3/11/2026 starting at 11:04 a.m., of Staff A, Registered Nurse (RN) preparing to check Resident #12's blood sugar prior to meal and administer insulin. Staff A checked the insulin orders and did not perform hand hygiene prior to applying gloves. Staff A removed the insulin pen from the medication cart and an insulin pen needle. Staff A turned the dial to 2 units without the insulin pen needle on it and pushed the trigger. Staff A with the soiled gloves still on applied the insulin pen needle and turned the dial to 10 units. Staff A was unsure of which side she was to administer the insulin and left the room with the soiled gloves on. Staff A reentered the room with gloves on and moved the shirt up, and pulled the edge of the residents…

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, infection control policy and staff interview, the facility failed perform proper hand hygiene and adhere to infection control guidelines during medication pass for 1 of 4 residents observed (Resident #12) The facility reported a total census of 32 residents.Findings include: During an ongoing observation on 3/11/2026 starting at 11:04 a.m., of Staff A, Registered Nurse (RN) preparing to check Resident #12's blood sugar prior to meal. Staff A removed items needed for blood sugar check. Staff A without performing hand hygiene applied gloves. With gloves on locked the medication cart, knocked on the residents door, opened the door to the residents room, picked up the barrier and placed the barrier onto the bed and placed supplies on the barrier. Staff A with soiled gloves opened an alcohol swab and cleaned the area on the resident's finger, with soiled gloves still on and used the glucose monitor to check the resident's blood sugar. With the soiled gloves on Staff A cleaned up her supplies and barrier and removed one glove. Staff did not perform hand hygiene.…

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, clinical record review, staff interviews and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 2 of 13 residents reviewed (Resident #8 and #17). The facility failed to obtain and complete a treatment order for Resident #8's open area to the right buttocks. The facility also failed to complete neurological assessments after an unwitnessed fall and failed to document urinary assessment after suspecting a urinary tract infection after the fall for Resident #17. The facility reported a census of 38 residents. Findings include: 1. Resident #8's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 08, indicating moderately impaired cognition. The MDS identified Resident #8 required substantial/maximal assistance with bed mobility and transfers. The MDS documented Resident #8 was…

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, staff interview, and clinical record review the facility failed to provide appropriate catheter care for 2 of 2 residents reviewed (Resident #12 and #31). The facility reported a census of 38 residents. Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #12 was dependent on staff with transfer to the toilet and toileting hygiene. The MDS indicated that Resident #12 has an indwelling catheter. Resident #12's MDS included diagnoses of cerebrovascular accident (CVA), benign prostatic hyperplasia, neurogenic bladder (bladder dysfunction caused by nervous system conditions) and retention of urine. The Care Plan with target date of 4/8/25 identified Resident #12 had an indwelling catheter due to a neurogenic bladder. The Care Plan directed staff to ensure a dignity bag remained in place, monitor tubing for kinks/leaks and ensure tubing…

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 clinical record review, staff interviews and policy review the facility failed to conduct appropriate assessments, interventions and timely Physician notifications for 1 of 3 residents reviewed (Resident #17) for weight loss. The facility reported a census of 38 residents. Findings include: Resident #17's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS identified Resident #17 required set up or clean up assistance with eating. The MDS documented Resident #17 did not have a 5% weight loss in the last month or 10 % weight loss in the last 6 months. Resident #17's MDS included diagnoses of cancer, anemia, heart failure, and cerebrovascular accident (CVA) with hemiplegia affecting the left side. The Care Plan with target date 4/2/25 revealed Resident #17 had a potential for altered nutritional status related to stroke, diagnosis of heart failure, anemia and history of urinary tract infection.…

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 staff interview, the facility failed ensure a resident had a current order for administration of as needed (PRN) psychotropic medications for 1 of 5 residents reviewed (Resident #28). The facility reported a census of 38 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #18 scored 7 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident had diagnoses including Alzheimer's disease, stroke, depression, restlessness and agitation. The Care Plan with a goal target date of 3/26/25 identified Resident #18 utilized a psychotropic medication related to Alzheimer's disease, depression, and agitation/anxiety (end of life). Interventions included administering medications as ordered. Hospice orders dated 9/26/24 included Lorazepam 0.5 mg tablet, 1/2 tab every 4 hours PRN for agitation/anxiety. A Pharmacy Review-General Recommendation documented the need for follow up with the provider as the order…

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 clinical record review, staff interviews and policy review, the facility failed to utilize a Paid Nutritional Assistant (PNA) appropriately for 1 of 6 residents reviewed (Resident #14). The facility reported a census of 38 residents. Findings include: Resident #14's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 08, indicating moderately impaired cognition. The MDS identified Resident #14 required partial/moderate assistance with eating. The MDS documented Resident #14 has had weight loss and was on a mechanically altered diet. The Care Plan with a target date 3/5/25 revealed Resident #14 had the potential risk for altered nutritional status related to increased weakness and comfort care. The Care Plan directed staff to assess for signs and symptoms of aspiration or any difficulty swallowing. Review of the clinical record revealed Resident #14 had a diagnosis of dysphagia (difficulty swallowing). A Physician Order dated 12/7/22 directed…

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 staff interview, the facility failed to ensure a resident received a pneumococcal vaccine for 1 of 5 residents reviewed (Resident #28). The facility reported a census of 38 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #28 had short term memory problems and modified independence with cognitive skills for daily decision making. The resident had diagnoses including down syndrome and cognitive communication deficit. The MDS indicated the resident's pneumococcal vaccine was not up to date, and not offered. An admission Influenza and Pneumococcal Vaccination Information form showed Resident #28's responsible party signed the resident would like to receive the pneumonia vaccine, dated 8/19/24. The clinical record lacked documentation the resident had received the pneumonia vaccine or why she had not. On 2/13/25 at 8:42 a.m. the Director of Nursing (DON) brought a Resident Vaccine Audit and wrote in the date started 12/1/24. She stated…

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, record review, and staff interview, the facility failed to assure each resident received care in a manner that promoted enhancement of their quality of life for 3 of 3 residents reviewed, (Resident #82, #21 and #12). The facility reported a census of 30 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #82 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required extensive assistance with bed mobility, transfer, ambulation, dressing, toilet use, personal hygiene and bathing. The resident had diagnoses including arthritis, osteoporosis, muscle weakness and chronic kidney disease. The Care Plan with a goal target date of 12/5/23 identified the resident's daily routine was important to her. She had certain preferences she would like to maintain while she stayed in the facility. She liked to choose how she spent the day, how her furniture was arranged, and specific morning, bedtime…

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, record and chart review the facility failed to accurately document a resident's specific need for 2 of 15 residents reviewed (Resident #7 and Resident #29). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnosis of hypertension, Parkinson ' s disease, depression, and anxiety. The MDS showed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS revealed the facility failed to code a wander/elopement alarm on the MDS in section P for Restraints and Alarms. Review of the Physician Orders revealed the wander guard was placed on Resident #7 on 9/14/23. Observation on 2/26/24 revealed Resident #7 had a wander guard bracelet on the ankle. 2. The MDS assessment dated [DATE] for Resident #29 documented diagnosis of weakness, covid-19, hypokalemia and hypoxemia. The MDS showed a BIMS score of 15 indicating no cognitive impairment. The MDS revealed…

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, record review, and staff interview, the facility failed to have sufficient staff to answer call lights in a timely manner for 1 of 3 residents reviewed (Resident #82) and multiple call light times greater than 15 minutes in the 7 day look back period. The facility reported a census of 30 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #82 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required extensive assistance with bed mobility, transfer, ambulation, dressing, toilet use, personal hygiene and bathing. The resident had diagnoses including arthritis, osteoporosis, muscle weakness and chronic kidney disease. The Care Plan with a goal target of 12/5/23 identified the resident needed assistance with her activities of daily living related to advanced age and arthritis. The interventions included the resident was alert and oriented, able to communicate needs and use the call light.…

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.