Valley Vista Post Acute

In the surveyor’s words

From the most serious findings on record at Valley Vista Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684May 26, 2022

  Based on interview and record review, the facility failed to provide two of three residents (Resident 1 and 2) care and treatment based on professional standards of practice when: 1 A. Resident 1's wound care needs for her foot were not addressed. B. Resident 1's change of condition related to slurred speech, nausea and vomiting were not addressed and communicated with the resident's physician. C. Resident 1's laboratory orders were not carried out. In addition, abnormal lab results were not communicated with the resident's physician. D. Resident 1's blood sugar levels were not monitored. 2. […]

• Actual harm, isolatedF604May 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure Resident 19, a vulnerable resident (person who cannot move or think independently), received care that was provided in a respectful and dignified manner and was free from physical restraints, when: -Certified nursing assistant (CNA) 30 used a bath towel to physically restrain Resident 19 when the resident refused care. -Resident 19's privacy curtain was left open during brief changes and personal care. Resident 17 (the roommate of Resident 19) was able to observe the personal care provided to Resident 19. As a result of these deficient practices, Resident 19 experienced care that a reasonable person would find humiliating, embarrassing, and distressing. […]

• No harm, potential for more than minimal, patternF605Sep 11, 2025

  Based on interview and record review, the facility failed to ensure that four out of five sampled residents (Residents 2, 10, 19 and 49) were free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medications when: 1. For Resident 10, the facility did not implement resident specific non-pharmacological interventions (NPIs, behavioral treatments that do not involve medications) for the use of clonazepam (medication used to treat anxiety), mirtazapine (medication used to treat depression), risperidone (antipsychotic medication that balances certain chemicals in the brain to help a person feel calmer and think clearly), buspirone (medication used to treat anxiety) and sertraline (medication used to treat depression).2. […]

• No harm, potential for more than minimal, patternF755Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to provide pharmacy services in accordance with accepted standards of practice when:1. Random controlled medication (medications with a high abuse potential) use audit for five of six sampled residents (Residents 3, 7, 25, 40 and 55) showed that medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. This failure had the potential for diversion (unlawful distribution or use), mismanagement of controlled medications, and the potential to not meet the needs of the residents in the facility. 2. […]

• No harm, potential for more than minimal, patternF759Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater, when observation of 42 opportunities during medication administration resulted in five errors. The calculated medication error rate was 11.9%.This failure resulted in1. Placing Resident 29 at risk of not breaking down and absorbing nutrients from food when Licensed Nurse (LN) 1 crushed and administered pancrelipase (digestive enzymes used to break down food during digestion) Delayed Release (DR, designed to release medication slowly over a period).Placing Resident 29 at risk of inadequate pain relief when LN 1 crushed and administered gabapentin (medication used for pain).2. […]