Valley Oaks Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Mar 23, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF803Jan 18, 2024

  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. […]

• No harm, potential for more than minimal, patternF584Mar 23, 2026

  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. […]

• No harm, potential for more than minimal, patternF880Mar 25, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF641Mar 23, 2026

  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. […]