Valle Verde Health Facility

In the surveyor’s words

From the most serious findings on record at Valle Verde Health Facility, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 29, 2026

  Based on interview and record review, the facility failed to prevent the development of an unstageable (a severe wound where the true depth and extent of tissue damage cannot be determined because the wound bed is completely obscured by dead tissue) pressure ulcer (localized damage to the skin and underlying soft tissue) in one of three sampled residents (Resident 1). Resident 1 was admitted to the facility with a left ankle-foot orthosis boot (AFO - a medical brace designed to support the ankle) status post-surgery and was found with an unstageable pressure ulcer on the left foot approximately 6 weeks later. […]

• No harm, potential for more than minimal, widespreadF801Jan 10, 2025

  Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when the Director of Food and Nutrition Services (referred to as Director of Dining Services (DDS)), albeit was a full time (FT) position, DDS was responsible for not only the main kitchen that provided foodservice for the residents residing in the Health Center (skilled nursing facility), but also responsible for two other foodservice operations located on the Continuing Care Retirement Community (CCRC) campus, community Meals on Wheels, and providing food for another contracted small health facility. […]

• No harm, potential for more than minimal, widespreadF812Jan 10, 2025

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service when: 1. TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not consistently and accurately cooled down to ensure food safety. 2. The ice machine, located in a pantry near a nursing station, utilized for residents was not maintained in a sanitary condition. 3. There were unsanitary conditions in the main kitchen related to: 3a. Kitchen floors with build -up of dried food debris. 3b. Floor drains with build- up of dried food debris. 3c. Clean equipment stored on unclean shelves. 4. […]

• No harm, potential for more than minimal, isolatedF578Jan 9, 2026

  Based on interview and record review, the facility failed to ensure the POLST (Physician Orders for Life-Sustaining Treatment -a medical document that translates treatment preferences into actionable medical orders) was signed by the Responsible Party (RP- one who has authority to make healthcare decisions) for one of 4 sampled residents (Resident 14).This failure had the potential to result in Resident 14's wishes regarding medical treatment not being followed.Findings:During a review of Resident 14's POLST (Physician Orders for Life-Sustaining Treatment [a medical document that translates treatment preferences into actionable medical orders]), dated 11/10/25, Resident 14 signed the POLST consenting to DNR (Do Not Attempt Resuscitation), Selective Treatment - goal of treating medical… […]

• No harm, potential for more than minimal, isolatedF656Jan 9, 2026

  Based on observation, interview, and record review, the facility failed to:1.Develop a care plan and interventions for hearing impairment for one of two sampled residents (Resident 8). This failure had the potential for Resident 8's hearing impairment to worsen and thus impact the resident's quality of life.2.Implement care plan interventions for Resident 11 related to access to call light and repositioning in bed. This failure had the potential for Resident 11 not to receive the necessary care needed. 1.During a record review of Resident 8's comprehensive assessment, dated 12/04/25, this indicated Resident 8 was assessed to have hearing impairment.During an observation on 01/07/26 at10:55 a.m. […]