Valley Senior Living On Columbia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on -review of a facility reported incident (FRI), record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced unwanted sexual contact from another resident (Resident #1). Failure to protect residents from sexual abuse places all residents at risk for psychosocial harm and mental and emotional distress. Findings include:The surveyors determined a deficient practice existed on 08/19/25. the facility implemented and completed corrective action on 08/19/25.Review of the facility policy titled Valley Senior Living Personnel Policy and Procedure 207.7 occurred on 11/26/25. This policy, dated October 2024, stated, . Every resident has the right to be free from abuse .Review of the FRI identified on 08/19/25 at 8;30 a.m., . Residents [#1 and #2] were self mobilizing their wheelchairs after breakfast down the hallway. [Resident #1] wheeled next to [Resident #2], reached out and…

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, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 35 sampled residents (Resident #36). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2024, page A-32, stated, . Coding Instructions. Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . Review of Resident #36's medical record occurred on all days of survey. The record included diagnoses of bipolar disorder, Tourette's disorder, and autistic disorder. A comprehensive MDS, dated [DATE], showed the facility failed to code Section A1500 for a serious mental illness. During an…

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, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 12 sampled residents (Resident #30, #153, and #275) observed during cares/wound care. Failure to practice infection control standards related to enhanced barrier precautions (EBP), perineal care, catheter cares, dressing changes, and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Dressings: Dry and Moist-to-Dry occurred on 06/18/25. This policy, dated April 2022, stated, . Apply antiseptic ointment (if ordered) with sterile cotton-tipped swab or gauze . Dispose of gloves and perform hand hygiene. Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/19/25. This policy, dated April 2025, stated, . EBPs apply when: A resident . has a wound. Indwelling medical devices include . urinary catheters . EBPs employ targeted gown and glove use…

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, review of the facility policy, and staff interview, the facility failed to develop a comprehensive care plan for 2 of 5 sampled residents on oxygen (Resident #32 and #47). Failure to develop a comprehensive care plan limited staffs' ability to communicate needs and ensure the continuity of care. Findings include: Review of the facility policy titled Care Plan, Comprehensive Interdisciplinary occurred on 05/16/24. This policy, dated 03/2017, stated, . The comprehensive care plan must describe the following: 1. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. - Review of Resident #32's medical record occurred on all days of survey. Diagnoses included chronic obstructive pulmonary disease, heart disease, and palliative care. Physician's orders stated the following: . O2 [oxygen] PRN [as needed] 1.5 Liters per nasal cannula for comfort as needed and every day shift daily. O2 sat [saturation]…

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, record review, and review of facility policy, the facility failed to provide care and services to prevent the development of pressure ulcers for 1 of 8 sampled residents (Resident #165) with prevalon boots (used for pressure relief) as ordered by the provider. Failure to apply the pressure relief boots as ordered may result in the development/worsening of pressure ulcers. Findings include: Review of the facility policy titled Standards of Care occurred on 05/16/24. This policy, dated 05/01/24, stated, . Additional pressure relief measures will be maintained for residents who are considered at risk for pressure injury. Review of Resident #165's medical record occurred on all days of survey. Diagnoses included a stage three pressure ulcer on the right ankle. The current care plan stated, I have a potential impairment to skin integrity r/t [related to] Impaired [sic] mobility . I need assistance to apply bilateral prevalon boots, on while in bed. A provider's order, dated 11/13/23, stated, Prevalon boot to BLE [bilateral lower extremities] for potential for high…

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 provide appropriate toileting for 1 of 29 sampled residents (Resident #98) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: Review of Resident #98's medical record occurred on all days of survey. Diagnoses included skin breakdown. The quarterly Minimum Data Set (MDS), dated [DATE], identified frequently incontinent of urine, extensive assist of two for toileting, and at risk for pressure ulcers. The current care plan stated, . at risk for alterations to skin integrity . TOILET USE: I need assist of 2 with total lift . I am incontinent of bowel and bladder . * Observation on 05/13/24 at 4:09 p.m. showed Resident #98 sitting in the wheelchair in her room with urine on the floor under the wheelchair. *…

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 record review and staff interview, the facility failed to ensure residents' records contained the hospice election form for 1 of 5 sampled residents (Resident #79) receiving hospice services. Failure to obtain this document limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: Review of Resident #79's medical record occurred on all days of survey and identified Resident #79 elected Hospice services on 04/29/24. The medical record lacked the hospice election form. During an interview on 05/15/24 at 5:07 p.m., an administrative nurse (#1) confirmed the medical record for Resident #79 lacked the hospice election form.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for (2 of 21) sampled residents (Resident #49, and #154) and one supplemental resident (Resident #56) observed during personal cares. Failure to follow infection control standards related to hand hygiene and emptying of a urinary bag has the potential to spread infection throughout the facility and could transmit those infections to residents, staff, and visitors. Findings Include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 05/15/24. This policy, revised in May 2023, stated, . all personnel shall follow the handwashing/hand hygiene procedures . 2. Before and after direct contact with residents. Review of the facility skills validation titled Emptying Urinary Drainage Bag occurred in 05/15/24. This skills validation, revised on February 2022, stated, . 8. Place graduate on paper towel. 9. Do not let spout or clamp touch the graduate. 11. Place graduate on a paper towel on a flat surface. - Observation on 05/13/24 at 2:09…

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, record review, and resident and staff interview, the facility failed to follow a physician's order for removal of a foley catheter for 1 of 7 sampled residents with a catheter (Resident #147). Failure to follow physician orders for the removal of the foley catheter and to attempt voiding trials may result in an increased risk of catheter associated urinary tract infections (CAUTI) and decreased quality of life. Findings Include: The facility failed to provide a copy of their policy addressing physician orders. During an interview on 06/06/23 at 03:50 p.m., Resident (#147) complained of having a catheter and stated, I want it out. Physician orders on 04/27/2023 at 7:23 a.m., stated, Attempt voiding trial with next scheduled catheter change (5-16-2023). Remove catheter in the morning. Leave out for 4 hours and push fluids. Resident to void immediately before bladder scan. Replace 16 Fr [French] foley catheter with 10 mL [milliliter] balloon if bladder scan amount 250 mL or greater. Update urology if he passed or failed voiding trial. Review of the resident's…

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, review of facility policy, record review, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 3 residents (Resident #56) observed during insulin administration. Failure to obtain an accurate label for an insulin pen following an order change may result in residents receiving too much/little insulin and/or having a negative reaction. Findings include: Review of the facility policy Medication Labeling occurred on 06/08/23. This policy, revised May 2016, stated, . All legend resident medications regardless of source shall be properly labeled as follows . If necessary, a signal type label shall be placed on the medication indicating that there has been a change order affecting the administration of the medication and that the nurse should turn to the resident's health record for correct information . Review of Resident #56's medical record occurred on 06/07/23. A physician's order, dated 04/28/23, included Lantus 10 units subcutaneous every morning. Observation on 06/07/23 at 8:16 a.m. showed Resident #56's Lantus Solostar…

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, review of facility policy, and staff interview the facility failed to store dietary supplements under safe and sanitary conditions in 2 of 5 medication carts (Riverside Long Hall and [NAME] Short Hall) observed. Failure to remove scoops in dietary supplements may result in contamination of supplements or spread of infection to residents. Findings include: Review of the facility policy, Dining Services Policy, occurred 06/08/23. This policy, revised 2017, stated, . Sufficient storage facilities are provided to keep food safe . and by methods designed to prevent contamination. Scoops are not to be stored in food or ice containers. - Observation on 06/06/23 at 3:10 p.m. of the Riverside Long Hall medication cart showed a container of PUSH Collagen Dipeptide Concentrate powder (a wound healing dietary supplement) for Resident #70 with a scoop in the container. - Observation on 06/06/23 at 4:30 p.m. of the [NAME] Short Hall medication cart showed a container of PUSH Collagen Dipeptide…

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.