Vancrest-Upper Valley

In the surveyor’s words

From the most serious findings on record at Vancrest-Upper Valley, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 21, 2026

  Based on record review, staff interview, observation, and policy review, the facility failed to properly assess and obtain consultation for existing pressure ulcers in a timely manner to prevent the worsening of a pressure ulcer. This resulted in Actual Harm on 06/26/26 when Resident #112 was admitted to the facility with a stage II pressure ulcer which was not assessed by the facility or the wound physician and deteriorated to a stage three pressure ulcer with slough to the wound bed. The facility also failed to administer pressure ulcer treatment per the physician's order. This affected one (Resident #112) of two residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF760Jul 7, 2021

  Based on medical record review, observations, resident and staff interview, policy review and review of medication information from Medscape, the facility failed to administer insulin as physician ordered resulting in a significant medication error. This resulted in actual harm when staff failed to add Resident #10's insulin order to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#10) out of four residents reviewed for insulin administration. Facility census was 100. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE], transferred to the hospital on 06/13/21 and returned to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2026

  Based on observation, staff interview, manufacturer instruction, and policy review, the facility failed to maintain the ice machine and distribute food in a sanitary manner. This had the potential to affect all of the residents in the facility with the exception of four facility-identified (Residents #10, #32, #37 #55) who did not receive food from the facility kitchen. The facility census was 114 residents.Findings include: 1. Review of the monthly ice machine cleaning log revealed the kitchen ice machine was cleaned on 06/05/26. Observation 07/14/26 at 10:02 A.M. with the Dietary Manager (DM) revealed the ice machine had a thin black layer along the lip of the ice chute. The DM wiped the lip of the ice chute with a damp cloth and a black substance came off the chute onto the cloth. […]

• No harm, potential for more than minimal, widespreadF887Jul 21, 2026

  Based on staff interview and policy review the facility failed to offer and administer the Coronavirus (COVID-19) vaccines to employees. This had the potential to affect all residents in the facility. The facility census was 114 residents. Findings include:Interview on 07/15/26 at 3:32 P.M. with Business Office/Human Resource Manager (BO/HRM)#402 confirmed there are no employee vaccinations in the employee files. BO/HRM #402 stated Infection Control Nurse (ICN) #408 would have any employee vaccine forms.Interview on 07/15/26 at 3:40 P.M. with ICN #408 verified there was no documentation of any employee being offered or given the COVID vaccines per the COVID policies. […]

• No harm, potential for more than minimal, patternF567Jul 21, 2026

  Based on medical record review, review of resident fund accounts, staff interview, and policy review, the facility failed to ensure residents' personal funds were deposited in an interest-bearing account. This affected four (Residents #11, #22, #40, and #77) of six residents reviewed for resident fund accounts. The facility census was 114 residents. Findings include: 1.Review of the medical record for Resident #11 revealed an admission date of 01/27/25 with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension (HTN), and Alzheimer's disease. Review of the resident funds authorization form for Resident #11 dated 12/03/25 revealed the resident authorized the facility to manage the resident's funds. […]