Valley Falls Terrace

In the surveyor’s words

From the most serious findings on record at Valley Falls Terrace, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF732May 9, 2024

  Based on interview, record review, and review of facility policy, the facility failed to post daily staffing for 2 days out of 4 months reviewed. Findings include: Review of the facility policy titled, Posting of Licensed and Unlicensed Direct Care Staff revised in 2017 states, Direct care staffing for licensed and unlicensed staff is posted on a daily basis. Review of the facility's posted staffing sheets for 03/01/24 thru 05/07/24, revealed on 03/16/24 and 03/17/24, there was no documentation of hours for Registered Nurses (RN)s, Licensed Practical Nurses (LPN)s, or Certified Nurse Assistants (CNA)s for all three shifts. During an interview on 05/08/24 at 11:59 AM, the CNA Staffing Coordinator stated, I complete the weekend staffing sheets afterward on Mondays. […]

• No harm, potential for more than minimal, widespreadF761May 9, 2024

  Based on review of facility policy, observation, and interviews, the facility failed to remove expired medications and biologicals in 2 of 2 medication storage rooms, 1 of 2 treatment carts, and 1 of 4 medication carts. Findings include: Review of the facility policy titled, Pharmacy Services Policies and Procedures dated 04/17/24, revealed, Section 8-Medication Storage Policy: 1. Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . Procedures: 5. Medications with manufacturer's expiration date expressed in month and year (e.g., May, 2019) will expire on the last day of the month. (unless a sooner expiration date has been placed on the package by the pharmacy). 6. […]

• No harm, potential for more than minimal, widespreadF812May 9, 2024

  Based on observations, interviews, and facility policy review, the facility failed to ensure foods that were stored in the freezer, refrigerators and dry food storage were properly sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date. This failure had the potential to cause foodborne illnesses in all residents who received meal trays from the kitchen. Findings include: Review of the facility policy titled, Nutrition Orientation & Competency Policies and Procedures, with a complete revision date of [DATE], revealed, Food storage: label and date food items removed from their original containers; Always cover, label and date leftovers that are to be stored. […]

• No harm, potential for more than minimal, isolatedF641Apr 16, 2025

  Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one of 24 sampled residents (Resident (R)6). R6's MDS was not accurately coded to indicate the continuation of Hospice services with a terminal diagnosis for two quarterly MDS assessments. The failure to accurately code/assess the resident's condition had the potential to affect the care planning for the resident to receive all required services. Findings include: Review of pages J27 and J28 of the October 2024 RAI Manual revealed, . Steps for Assessment 1. […]

• No harm, potential for more than minimal, isolatedF689Apr 16, 2025

  Based on observation, record review, interview, and facility policy review, the facility failed to ensure the environment was free of accident hazards when water temperatures were not maintained at a safe temperature for four of four resident rooms (Rooms 100, 101, 114, and the room of Resident (R) 23) out of a total of 40 resident rooms and one of one shower room where water temperatures were measured. This failure had the potential to cause residents to incur a burn from the high water temperature. Findings include: Review of the facility's policy titled, Preventative Maintenance Procedure, revised 07/26/17, revealed, . […]