Valley View Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Valley View Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 29, 2022

  Based on observation, interview, and record review the facility failed to ensure the residents' environment was free from accident hazards, including securing portable oxygen tanks (contains compressed oxygen). The failure to secure portable oxygen tanks in 3 (Resident 90, 84 & 66) resident rooms and in an oxygen storage room placed the residents at risk for serious adverse outcomes if oxygen tanks fell or tipped over, with the potential for an explosion and/or serious bodily injury, and constituted an immediate jeopardy (IJ). On 04/22/2022 at 10:57 AM an IJ was identified and the Provider was informed. […]

• Immediate jeopardy, isolatedF678Dec 12, 2022

  Based on interview and record review the facility failed to have systems in place that ensured basic life support was initiated, including Cardio-Pulmonary Resuscitation (CPR- an emergency procedure consisting of chest compressions combined with giving breaths of air) when one of one residents reviewed for emergency situations (Resident 1) was found unresponsive and required immediate staff action. The failure of facility staff to initiate basic life support, including CPR potentially contributed to the residents unsuccessful response to CPR when initiated by 911 emergency responders and increased the likelihood/risk of serious imminent harm for all residents who choose to have CPR initiated in an emergency. On [DATE] at 5:13 PM, the facility was notified of an immediate jeopardy in F678. […]

• Actual harm, patternF689Aug 16, 2022

  Based on observation, interview, and record review the facility failed to provide adequate supervision to ensure resident safety for 4 (Resident 1, 2, 3 & 4) of 5 residents reviewed for accidents. The failure to conduct fall risk assessments, identify and implement fall prevention interventions, conduct root cause analyses after resident falls resulted in harm for Resident 1 who sustained a [CONDITION(S)] and head injury on two separate unsupervised falls, harm for Resident 2 who sustained a [CONDITION(S)], psychosocial harm for Resident 3 who fell after distress caused by the behavior of their roommate, and placed all residents at risk for repeated falls, the potential for significant injury, and diminished quality of life. Findings included . […]

• Actual harm, isolatedF684Apr 29, 2022

  Based on observation, interview, and record review the facility failed to ensure 3 (Residents 36, 251 & 153) of 17 residents reviewed, received the necessary care and services in accordance with professional standards of practice and their comprehensive person-centered care plan. The failure to implement monitoring and interventions for skin care (Resident 251),and air mattress settings (Resident 153) resulted in the potential for unmet care needs and diminished quality of life. The failure to provide physician ordered treatments for 1 (Resident 36) of 3 residents reviewed for non-pressure skin issues resulted in worsening of the skin condition, discomfort, and psychological distress to the resident. […]

• Actual harm, isolatedF686Apr 29, 2022

  Based on observation, interview and record review the facility failed to ensure care is provided consistent with professional standards of practice to prevent and/or provide treatment and services for pressure ulcers for 3 of 8 (Resident 3, 97, & 76) residents reviewed for Pressure Ulcers (PU). Failure to identify and assess changes in skin condition, notify the practitioner to obtain orders for treatment, and complete weekly documentation of PU progress caused harm to Resident 3 who obtained two stage four PUs on the right hip, one stage 4 PU on the right outer ankle and one stage 4 PU on the right outer foot. Failure to implement preventative measures (Residents 97 &76) such as positioning, placed residents at risk for deterioration in skin condition. […]