Valley Oaks Care Center

Based on observation, interview and facility policy review, the facility failed to ensure proper sanitation and food storage practices. This had the potential to effect all 38 residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #13, #15, #17, #18, #19, #20, #23, #24, #25, #26, #27, #28, #29, #32, #34, #36, #37, #38, #39, #40, #42, #43, #45, #46, #47, #55, #56) who ate food from the facility kitchen. The facility census was 43.Findings include:Observation on 03/16/26 at 10:30 A.M., the walk in freezer contained undated breadsticks stored in an unmarked clear bag. The dry storage area contained multiple food items open to air, not sealed, and not dated, including: a two pound three ounce bag of Corn Flakes, a two pound three ounce bag of Bran Flakes (closed but undated), a 16-ounce bag of Lays Classic chips, a 25 pound bag of all purpose flour, and three unlabeled, undated bags containing a brown colored substance. Dietary Manager #524 reported, I am not sure what that could be.Observation on 03/17/26 at 10:00 A.M. with Dietary Manager #524 revealed a grease residue line…

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 comfortable, homelike environment when maintenance failed to maintain water temperatures in resident rooms. This affected six (Residents #24, #37, #26, #14, #46, and #42) residents reviewed for homelike environment and had the potential to affect all residents in the facility. The facility census was 43.Findings include:On 03/16/26 at 8:42 A.M., an interview with Resident #24 revealed the water in her sink did not get warm unless it ran for a really long time. Observation at the time of the interview revealed the water in the sink was cold, even after running for over two minutes. The resident stated, I shower in the shower room, so it really only is a problem to wash my face. She indicated the certified nurse aides (CNAs) mainly used the water to clean up her roommate (Resident #37), so she just dealt with it.On 03/16/26 at 8:44 A.M., an observation of water temperature in Resident #26's room revealed the water was cold at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessments were accurately completed for Residents #7 and #12. This affected two residents (#7 and #12) of 16 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 43.Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 04/15/25 with diagnoses including depression, dementia and anxiety. Review of the physician's orders for Resident #7 revealed she had an order for Risperdal 0.25 milligrams (mg) at bedtime for paranoia and agitation dated 07/16/25. Risperdal was classified as an antipsychotic medication. Review of the 02/19/26 modified annual MDS 3.0 assessment for Resident #7 revealed on section N415 under high-risk drugs classes she was taking an antipsychotic. However, under section N450 antipsychotic medication review, the facility answered that antipsychotics were not received since admission or the prior assessment. Interview on 03/23/26 at 9:43 A.M. with…

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, review of facility policy and interview, the facility failed to ensure oxygen was provided to Resident #3 as ordered by the physician and/or failed to ensure orders were updated to reflect the current plan for treatment. This affected one resident (#3) of two residents reviewed for respiratory care. The facility census was 45. Findings include:Review of the medical record for Resident #3 revealed an admission date of 11/18/25 with diagnoses including chronic atrial fibrillation, depression, diffuse traumatic brain injury with loss of consciousness of unspecified duration, dysphagia, heart failure and muscle weakness.Review of physician orders for Resident #3 revealed an order dated 11/18/25 to obtain the resident's vital signs monthly. Review of a care plan for Resident #3, (revised 12/01/25), revealed a focus of care for impaired respiratory status related to the resident being oxygen dependent. The goal was for the resident to be free from signs and symptoms of hypoxia. Interventions (dated 11/19/25) included oxygen as ordered or as needed…

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, interview and facility policy review, the facility maintain a medical record in accordance with accepted professional standards and practices, resulting in inaccurate documentation for Resident #3. This affected one resident (#3) of 16 residents whose records were reviewed for accuracy. The facility census was 43.Findings include:Review of the medical record for Resident #3 revealed an admission date of 11/18/25. Diagnoses included alcohol abuse, anemia, dementia, mild without behavioral disturbance, difficulty in walking, disorder of prostate, essential hypertension, history of falling, insomnia, neuromuscular dysfunction of the bladder, pressure ulcer of right buttock Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral region, alcoholic polyneuropathy, chronic atrial fibrillation, depression, diffuse traumatic brain injury with loss of consciousness of unspecified duration, dysphagia, heart failure, unspecified, hyperlipidemia, muscle weakness, osteomyelitis of vertebra, sacral and sacrococcygeal region,…

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, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff implemented proper infection control practices while providing care to residents on enhanced barrier precautions. This affected two of three residents (#13 and #45) reviewed for infections and had the potential to affect 25 additional residents (#29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #31, #42, #43, #44, #46, #47, #48, #49, #50, #52, #52, #53 and #54) who resided on the 200 hall where State Tested Nurse Aide (STNA) #340 contaminated high touch surfaces. The facility census was 54. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 02/20/24 with diagnoses including pneumonia, type two diabetes mellitus, dependence on renal dialysis, dislocation of the tarsometatarsal joint of the right foot, and osteomyelitis (infection of the bone) of the right ankle and foot. Review of the admission Minimum Data Set (MDS) assessment completed on 02/24/24 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.

Based on interview, food committee meeting minutes and facility menu review, the facility failed to provide a menu which offered a variety of items served at the breakfast meal. This had the potential to affect 52 residents who received meals from the kitchen. The facility identified Resident #13 as receiving nothing by mouth. The facility census was 53. Findings include: Review of facility food committee meeting minutes dated 07/31/23 revealed concern related to repeating menu items was noted. Review of the facility's fall 2023-24 four-week (28 day) menu revealed scrambled eggs were served 14 out of 28 days. For week three, scrambled eggs were served five days (Sunday, Monday, Tuesday, Thursday, and Saturday) out of seven days and three days in a row between the end of week four and the beginning of week one (week four Saturday, week one Sunday, and week one Monday). Interview on 01/17/24 at 11:56 A.M. with the Dietary Supervisor revealed she did have residents complain to her there was too much repetition of some items on the menu. Interview on 01/17/24 at 1:14 P.M. with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to accurately reflect residents' status on Minimum Data Set (MDS) assessments related to mental health status and oxygen use. This affected three (Residents #11, #21, and #33) of 24 residents whose assessments were reviewed. The facility census was 53. Findings include: 1. Review of Resident #11's medical record review revealed diagnoses including schizoaffective disorder (bipolar type), psychosis, pseudobulbar affect, depression, bipolar disorder and anxiety disorder. A Preadmission Screen and Resident Review dated 07/05/22 indicated Resident #11 had no indications of serious mental illness. Resident #11 was hospitalized between 11/14/22 and 12/07/22. Review of a Preadmission Screen and Resident Review Determination (PASRR) determination revealed Resident #11 was approved for nursing facility services. The attached summary report dated 12/01/22 indicated Resident #11 was first medically hospitalized ( for increased ammonia level in…

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 medical record review and staff interview the facility failed to ensure preadmission screening and record review assessments were resubmitted after a new major mental illness diagnosis was added for Resident #43. This affected one (Resident #43) of four residents reviewed for preadmission screening and resident review. The facility census was 53. Findings include: Review of Resident #43's medical record revealed an admission date of 04/12/23 with diagnoses that included chronic obstructive pulmonary disease, hyperlipidemia, major depression and anxiety. A Preadmission Screening and Resident Review (PASARR) completed on 04/11/23 indicated Resident #43 had only anxiety. Upon admission to the facility, Resident #43 was prescribed Navane (antipsychotic medication) five milligrams (mg) twice daily which the resident was on long term prior to admission. Further review of the medical record, including psychiatrist evaluations, revealed the Navane was gradually reduced and discontinued on 06/06/23. 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, interviews, record review and facility policy, the facility failed to ensure oxygen tubing was changed weekly for Residents #33 and #51. This affected two residents (#33 and #51) of four residents reviewed for respiratory care. The facility census was 53. Findings include: 1. Review of the medical record for Resident #33 revealed an admission date of 09/24/21. Diagnoses included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact. Review of Resident #33's physician orders revealed an order dated 11/18/22 for oxygen two liters via nasal cannula, may titrate as needed. Review of Resident #33's care plan dated 09/25/21 revealed the resident had an impaired respiratory status related to anxiety, being a current smoker, and having shortness of breath. Interventions included oxygen as ordered by the physician. Observation and interview 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, medical record review, and interview the facility failed to monitor circulatory status of a resident who had an edematous (swollen) left foot and studies indicating a thrombus (blood clot). This affected one (Resident #97) of 17 residents observed for evidence of edema. Findings include: Observations on 02/01/22 at 8:38 A.M. and 11:06 A.M. and on 02/02/22 at 7:50 A.M. and 12:20 P.M. revealed Resident #97 sitting on the side of his bed with his legs dangling off the side of the bed and his feet on the floor. Review of Resident #97's medical record revealed a diagnosis of a fracture of the left femur. On 12/30/21 an order was written for a venous ultrasound of the left lower extremity due to increased edema. Venous doppler results dated 12/31/21 indicated there appeared to be a thrombus (a blood clot formed in situ within the vascular system of the body and impeding blood flow) in the left gastrocnemius vein (The gastrocnemius vein is considered a deep muscular vein of the calf.) There was no evidence of circulatory assessments related to the thrombus. 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, medical record review and staff interview the facility failed to ensure range of motion services were provided for residents identified with a limitation in joint mobility. This affected one (Resident #26) of two residents reviewed for range of motion services. The facility census was 46. Findings include: Review of Resident #26's medical record revealed an admission date of 10/18/15 and a readmission date of 09/18/19 with diagnoses that included Alzheimer's disease with dementia and congestive heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment with a reference date of 12/31/21 indicated Resident #26 had limitation in range of motion to both upper and lower extremities. Further review of the medical record including a hospice recertification completed on 12/31/21 indicated Resident #26 had contractures to the bilateral legs and hands. Further review of the medical record found no evidence of any splint device use or any restorative services for joint mobility. No documentation was found to indicate a reason for joint mobility services not…

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 medical record review and staff interview the facility failed to ensure monthly pharmacy reviews identified physician orders were not being followed regarding acetaminophen administration. This affected one (Resident #12) of five residents reviewed for monthly pharmacy reviews. The facility census was 46. Findings include: Review of Resident #12's medical record revealed an admission date of 07/13/16 with diagnoses that included Alzheimer's disease with dementia, osteoarthritis and epilepsy. Review of the physician's orders revealed current orders for acetaminophen (analgesic) 650 milligram (mg) three times daily and Norco (hydrocodone and acetaminophen analgesic) 5 mg - 325 mg four times daily. A total of 3250 mg of acetaminophen was administered daily. Review of the Medication Administration Record (MAR) revealed acetaminophen and Norco administered daily as ordered for a total of 3.25 gm of acetaminophen administered each day. An additional physician's order indicated to not exceed 3 grams (gm) of acetaminophen daily. Review of monthly pharmacy recommendations 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.

Based on medical record review and staff interview the facility failed to ensure physician orders were followed regarding acetaminophen dosage. This affected one (Resident #12) of five residents reviewed for medication use. The facility census was 46. Findings include: Review of Resident #12's medical record revealed an admission date of 07/13/16 with diagnoses that included Alzheimer's disease with dementia, osteoarthritis and epilepsy. Review of the physician's orders revealed current orders for acetaminophen (analgesic) 650 milligram (mg) three times daily and Norco (hydrocodone and acetaminophen analgesic) 5 mg - 325 mg four times daily. A total of 3250 mg of acetaminophen was administered daily. Review of the Medication Administration Record (MAR) revealed acetaminophen and Norco administered daily as ordered with 3.25 gm of acetaminophen administered each day. An additional physician's order indicated to not exceed 3 grams (gm) of acetaminophen daily. Interview with the Director of Nursing on 02/02/22 at 8:40 A.M. verified Resident #12 received 3.25 gm of acetaminophen on 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.