Valley West Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Dec 7, 2022

  Based on observation, interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 2 of 2 sampled residents (#s 11 and 42) reviewed for medication administration. Resident 11 was administered an extended release antihypertensive medication in an inappropriate manner placing her/him at risk for clinical complications. Alteration of the medication's absorption properties can cause serious side effects up to and including fatal overdose. This failure was determined to be an immediate jeopardy situation. Findings include: 1. […]

• Actual harm, isolatedF692Dec 7, 2022

  Based on interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters of hydration and nutrition status for 5 of 9 sampled residents (#s 7, 16, 20, 54 and 259) reviewed for hydration and nutrition. Resident 7 experienced a severe weight loss. Findings include: 1. Resident 16 was admitted to the facility in 10/2022 with diagnoses including altered mental status and falls. Resident 16's record revealed fluid intake from 11/17/22 through 11/29/22 as follows: -11/17/22-1640 ml for the day -11/18/22-1,080 ml for the day -11/19/22-1,190 ml for the day -11/20/22-360 ml for the day -11/21/22-730 ml for the day -11/22/22-1,080 ml for the day -11/23/22-480 ml for the day -11/24/22-480 ml for the day -11/25/22-340 ml for the day -11/26/22-360… […]

• Actual harm, isolatedF689Jun 21, 2021

  Based on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety and failed to provide safe transfers for 2 of 3 sampled residents (#s 1 and 13) reviewed for accidents. Resident 1 fell out of a hygiene (designed for toileting and hygiene functions) sling and she/he sustained a left [CONDITION(S)]. Findings include: 1. Resident 1 admitted to the facility in 2018 with diagnoses including chronic heart failure and a left [CONDITION(S)]. A revised care plan dated 2/26/21 indicated Resident 1 was a two-person assisted transfer using a mechanical lift and hygiene sling to the bedside commode. […]

• Actual harm, isolatedF726Jun 21, 2021

  Based on interview and record review it was determined the facility failed to ensure staff were appropriately trained to provide safe transfers for a resident utilizing a hygiene sling for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 fell out of a hygiene (designed for toileting and hygiene functions) sling and she/he sustained a left [CONDITION(S)]. Findings include: 1. Resident 1 admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A revised care plan dated 2/26/21 indicated Resident 1 was a two person mechanical lift and hygiene sling to the bedside commode transfer. […]

• No harm, potential for more than minimal, widespreadF725Dec 7, 2022

  Based on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. On 11/29/22 at 10:17 AM Staff 7 (RN) stated that day was the first day she had two nurses on North Hall. On other days they were always short staffed on day and evening shifts and most weekends. Staff 7 stated she was unable to complete all of her daily assignments including: administering medications for 29 residents. […]