Valley View Home

Based on observations, interviews, and record review, the facility failed to provide meaningful activities for residents for 2 (#s 43 and 44) of 10 memory care residents. This deficient practice increased the risk of the residents becoming bored or escalating their behavior. Findings include: 1. During an observation on 6/16/26 at 2:45 p.m., staff members G and L were sitting at the nurses' station in the memory unit. Resident #43 was sitting in the dining room at a table by himself. Resident #43 was not involved in any activity. Resident #43 got up from his chair and went to his room and came back out a moment later, wandering in the hallway, and then to the common room where he sat in the recliner watching television. Resident #43 got back up a few minutes later and wandered back to his room. There was not an activity occurring at the time. 2. During an observation and interview on 6/16/26 at 3:10 p.m., resident #44 slept on the couch in the common area. Staff member G stated that resident #44 preferred to sleep on the couch throughout the day and night. Staff member G stated that…

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 ensure the IDT team verified a resident who was self-administering medication was determined to be clinically appropriate to self-administer medications, and medications were left for the resident to take independently, without supervision, for 1 (#4) of 26 sampled medication administrations. Findings include:During an observation on 6/17/26 at 11:27 a.m., staff member K prepared two acetaminophen 500 mg tablets for resident #4, placing them in a pill cup and taking them to the resident's room. Staff member K placed the medication cup on the bedside table and left the room without observing the administration of resident #4 taking the medications. During an interview on 6/17/26 at 11:28 a.m., staff member K stated resident #4 did not appear to have a self-administration of medication assessment. Staff member K stated she did not think about it before she left the medication without observing him taking the pills. Staff member K stated she knew she should stay with residents when administering medications…

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, the facility failed to ensure two vulnerable residents were not subjected to abuse, neglect, or psychosocial harm, when a staff member P physically and mentally abused resident #47 when the resident was resisting care, and when the same staff member left resident #43 unattended at an out of town appointment, neglecting her safety and supervision needs, for 2 (#s 43 and 47) out of 18 sampled and supplemental residents. Using the reasonable person perspective, both vulnerable residents may have ongoing psychosocial harm, fear, or behavior related to the abuse and neglect events involving staff member P. Findings include: 1. Review of a written warning, dated 3/5/26, showed staff member P left a cognitively impaired resident alone at an out-of-town appointment while the resident was in his care, neglecting the resident's safety. The resident was left in the corner of a corridor for at least an hour, with the wheelchair locked, and no one was there to assist or help the resident. When the resident was found by witnesses, she was observed to be…

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 boxes of resident food and drinks were stored off the floor in the kitchen area, and the improperly stored foods may be exposed to dust, pests, moisture, and other environmental hazards, affecting any resident eating food prepared or served by the kitchen. Findings include:During an observation on 6/16/26 at 7:42 a.m., one box of supplemental drinks was found on the floor upon entering the kitchen.During an observation on 6/16/26 at 7:46 a.m., two cases of Gatorade, one case of green beans, and one case of supplemental drink were on the dry storage floor.During an observation on 6/16/26 at 2:30 p.m., a box of supplemental drinks were found on the floor, propping open the kitchen door.During an interview on 6/17/26 at 8:35 a.m., staff member M stated the food delivery truck came late the previous day, she was aware of the food not being put away, and it was on the floor. Staff member M stated she was also aware of the supplemental drink being used to prop open the kitchen door. Staff member M stated that had been the…

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 failed to designate a full time DON. Findings include:During an interview on 1/29/26 at 9:48 a.m., staff members B and C stated the facility was without a DON for a little over a month. Staff member C stated the DON tasks were divided between the IDT.Review of an email from staff member A showed an advertisement for the DON position with a posting date of 9/8/25. The email goes on to show the IDT took over the DON tasks.During an interview on 1/29/26 at 10:00 a.m., staff member A stated the new DON started on 10/16/25.Review of an email sent by staff member A, dated 9/8/25 at 2:34 a.m., showed the previous DON no longer worked at the facility. There was no documentation available to show the prior DON's duties were specifically reassigned to an RN (or multiple RNs), until a new DON was recruited. Review of an email sent by staff member A, dated 10/16/25 at 3:26 p.m., showed staff member B started as DON on 10/16/25. The facility was without a DON for 37 days.

Based on interview and record review, the facility failed to ensure necessary and beneficial interventions were identified and implemented for the supervision of a resident (#1) who displayed various behaviors and this resident wandered into other residents' rooms which increased her risk of harm if others acted out on her. Resident (#1) had interactions with male residents, which were sexual in nature, and on one occasion, she was found in the male's room when the encounter was occurring. The facility implemented behavioral and medication interventions to help intervene in her behaviors but failed to implement a monitoring and supervision program that would meet resident #1's safety needs as related to her wandering and the sexual encounters she experienced. Staff documented she continued to have her baseline behaviors, and her behaviors changed in some areas, such as refusing medications and or care, but these were not clearly linked to the interactions she had with the two male residents. Resident #1 later transferred to the hospital and had not returned. Findings include:During…

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 failed to ensure an incident was reported within 24 hours of the date of the incident for 1 (#8) of 10 sampled residents. Findings include:During an interview on 1/29/26 at 9:48 a.m., staff members B and C stated the time frame for reporting incidents was 24 hours. Staff member B stated that as soon as we hear about a reportable, we start the investigation. Staff member B stated that the staff abuse training is done yearly. Staff member B stated there are in-services on abuse and reporting timelines throughout the year.During an interview on 1/29/26 at 10:00 a.m., staff member A stated the administrator, DON, and Social Services are responsible for obtaining statements from staff and residents. Staff member A stated the time frames for reporting to the State Survey Agency were two hours for serious bodily injury, or 24 hours if there is no serious bodily injury. Staff member A stated the findings are to be reported to the State Survey Agency within five days. Review of an incident of abuse submitted to the State Survey Agency, on…

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 failed to screen visitors for signs or symptoms of Covid-19, prior to entering the building, during a Covid-19 outbreak; failed to post transmission based precaution signage on the doors of Covid-19 positive residents, and failed to follow transmission based precautions for 4 (#s 15, 21, 26, and 27); failed to practice proper hand hygiene during a laundry pass for 2 (#s 14 and 31); and failed to follow enhanced barrier precautions for 3 (#s 14, 31, and 42) of 22 sampled residents. This deficient practice increased the risk of an individual contracting Covid-19, other viruses, or infections, for all residents, staff, or visitors. Findings include: 1. During an observation on 7/15/24 at 2:24 p.m., the facility had printed signs on the entrance doors showing there was a Covid-19 outbreak. Upon entrance into the facility, there was a sign in log, and N-95 masks. There was no staff member present, no screening equipment, or a questionnaire asking visitors about signs or symptoms of Covid-19. During an observation on 7/16/24…

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 failed to document resident declinations and education regarding the Covid-19 vaccine, for 2 (#s 11 and 27) of 5 sampled residents for immunizations. Findings include: A review of resident #11's preventive health care report, with a creation date of 12/14/23, showed, resident #11's resident representative refused the administration of the Covid-19 vaccination. A review of resident #27's preventative health care report, with a creation date of 12/14/23, showed, resident #27's resident representative refused the administration of the Covid-19 vaccination. A request was made on 7/17/24 at 10:16 a.m., for the signed declinations for resident #11 and #27. The signed declinations were not provided prior to the end of the survey. During an interview on 7/17/24 at 1:03 p.m., staff member J stated she did not have any signed declinations or documentation for resident #11 or #27's Covid-19 vaccinations. Staff member J stated she did not provide any education regarding the risks and benefits to the resident representatives for resident #11 or…

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 failed to follow outlined interventions for 1 (#25) of 3 residents sampled for weight loss. This deficient practice increased the risk of further weight loss for the resident who had a severe weight loss over a three month period. Findings include: During an observation on 7/16/24 at 8:11 a.m., resident #25 was asleep in her bed. Across the room, on her desk, was her full breakfast tray. During an observation on 7/16/24 at 9:00 a.m., resident #25 was still asleep and her full breakfast tray had been removed. During an observation on 7/17/24 at 8:09 a.m., resident #25 was sitting at the desk in her room with her breakfast tray. She was pushing eggs around with her silverware, but not consuming anything. During an observation on 7/17/24 at 12:07 p.m., resident #25 was sitting at the dining table in the resident common area. Her lunch was untouched in front of her. There were no staff around to cue the resident to eat. She got up from the table and wandered away down the hall. Review of resident #25's care plan, with a…

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 failed to ensure food items placed in the unit's nourishment refrigerator were dated and labeled with a resident name. This deficient practice increased the risk of a resident receiving incorrect, or out dated, food items. Findings include: During an observation on 7/17/24 at 7:54 a.m., there was an unlabeled and undated Tupperware container in the resident nourishment refrigerator, which was located at the end of the 100 hall. The contents of the container included a homemade, unknown yellow liquid substance. There was no indication of which resident the food belonged to or how long it was in the refrigerator. During an interview on 7/17/24 at 10:11 a.m., staff member L stated it was the responsibility of housekeeping to clean refrigerators in the resident common areas. Staff member L stated family members would often place items in the refrigerator without staff knowing. Review of the facility policy Use and Storage of Food Brought in by Family or Visitors, dated 12/27/18, showed, All food items that are already…

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 failed to ensure a resident received, or had the opportunity to receive, the pneumococcal vaccine series, for 1 (#15) of 5 sampled residents for vaccinations. Findings include: Review of resident #15's immunization record showed resident #15 had received one pneumococcal vaccine on 4/4/2018. The immunization record did not show what type of pneumococcal vaccine resident #15 had received. A review of a facility document titled, Pneumococcal Vaccine Informed Consent/Decline, showed, resident #15's resident representative signed for resident #15 to receive pneumococcal vaccines on 4/16/24. During an interview on 7/17/24 at 1:03 p.m., staff member J stated, [A Facility Name] works with us on providing vaccinations. Pneumococcal vaccines are not one the facility keeps in house. I just have not set up a clinic (vaccination) yet. It is just something I have not thought about doing yet. I am behind on looking at the immunizations. I have started asking the hospital to provide the pneumococcal vaccine prior to discharge. Review of a facility…

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 monitor a cognitively impaired resident with a known history of elopement attempts, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death for 1 (#2) of 2 sampled residents for elopements. Findings include: Review of a Facility Reported Incident, sent to the State Survey Agency for resident #2, dated 4/14/24, showed, Call received from another resident who was outside of facility reporting resident [#2] was outside at [School Name] playground alone. [Staff member name] received a call from [staff member] that she found resident at [School Name] and she would not get in her vehicle to bring her back to facility. [Staff member] arrived at [School Name] and [resident #2] was returned to facility by [staff member] in private vehicle. During an observation on 6/3/24 at 2:45 p.m., resident #2 was asleep in her room, one door away from the exit door. During an interview on 6/3/24 at 3:10 p.m., staff member D stated all residents at risk for…

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.