Valley Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 23, 2026

  Based on interview and record review, the facility failed to:Follow their policy and procedure (P&P) titled, WanderGaurd [sic](device used as safety protocol used to assist staff in monitoring people at risk for wandering near exits) Policy and Procedure for one of three sampled residents (Resident 1) when Respiratory Therapist (RT) responded to Resident 1's wanderguard alarm but did not check outside the surrounding area to ensure Resident 1 did not exit the facility premises.Ensure the every 30-minute monitoring log were completed for one of three sampled residents (Resident 1) with a history of elopement (occurs when a resident leaves the facility without authorization and/or any necessary supervision).These failures resulted in Resident 1 leaving the facility unaccompanied, missing for… […]

• Actual harm, isolatedF684Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to accurately assess, develop, and implement interventions as well as implement the facility's policy and procedures (P&P) for one of 22 Residents (Resident 3) when: Resident 3 had nine falls with injuries between admission date (9/5/25) to hospitalization (12/1/25). These failures resulted in Resident 3 having two hospitalizations (11/3/25 & 12/1/25) with multiple injuries including skin tears, a fracture (broken bone) in the neck of left femur (top part of leg bone is broken), which required surgical intervention, and need for rehabilitation (action of restoring someone to health or normal life through training and therapy after illness).Resident 3 was not accurately assessed for skin conditions based on shower… […]

• Actual harm, isolatedF837May 15, 2024

  Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Pressure Ulcer (or injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) Prevention for one of three sampled residents (Resident 1) when: 1. Resident 1 was not assessed for risk for developing pressure injuries upon admission. 2. Physician was not notified to obtain treatment for Resident 1's left heel redness. 3. A care plan (resident centered health document designed to facilitate communication among members of the care team with the resident) was not developed to address Resident 1's left heel redness. 4. […]

• Actual harm, isolatedF687Mar 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurses (LVN) 2 and LVN 4 performed skin assessment through direct observations, licensed nurses developed a care plan for the condition of the feet, licensed nurses notified the attending physician regarding the condition of the feet, Certified Nursing Assistant (CNA) 2 reported to the licensed nurses the condition of the feet, CNAs documented their observations of the condition of the feet using the facility's Comprehensive Certified Nursing Assistant Shower Review Form (CCNASRF), and the podiatrist provided appropriate medical foot care and treatment for two of two sampled residents (Resident 15 and Resident 36). […]

• Actual harm, isolatedF686Aug 3, 2022

  Based on interview and record review, the facility failed to: 1. Accurately assess and document the pressure ulcers (according to the National Pressure Ulcer Advisory Panel [NPUAP] a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with a shear), noted upon admission for one of four sampled residents (Resident 1). 2. Notify the Medical Doctor (MD) and obtain treatment orders for one of four sampled residents' (Resident 1) pressure ulcers. 3. […]