Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including a history of falls and stroke, was allowed to leave the facility on an overnight pass with family, as permitted by physician orders. However, staff could not produce the required sign-out documentation, and interviews confirmed the facility's protocol was not followed, resulting in a failure to ensure proper tracking of the resident's departure and return.
The facility failed to assess and identify residents for smoking upon admission, did not complete required quarterly smoking assessments, and allowed multiple residents to smoke unsupervised and possess lighters, including those with supplemental oxygen orders. Care plans were not updated to address safe storage, supervision, or use of smoking materials, and staff interviews confirmed a lack of consistent supervision and inventory of lighters, resulting in significant safety hazards.
Surveyors found that food items past their best buy dates were not discarded, food debris was present under kitchen equipment, a scoop was improperly stored on top of a grains container, and wet trays were stacked without air drying. These actions were not in accordance with the facility's food safety and sanitation policies, as confirmed by the Dietary Services Supervisor.
Surveyors observed that two dumpsters were overflowing with trash and had lids that were not completely closed. The Maintenance Supervisor and Administrator confirmed that this did not comply with facility policy, which requires dumpsters to be kept closed and free of litter. Review of the FDA Food Code also indicated that outside receptacles must have tight-fitting lids.
Nine residents did not receive documented written information about their right to formulate an Advance Directive. Although the Social Services Designee stated that written materials were offered and explained at admission, the required documentation was incomplete, and there was no evidence in the records that the information was provided, as required by facility policy.
The facility did not complete and submit comprehensive admission MDS assessments on time for two residents, as required by federal regulations. Review of records and staff interviews confirmed that the assessments were incomplete and lacked the necessary RN Assessment Coordinator verification, potentially delaying individualized care planning.
Two residents did not have individualized care plans developed to address their psychiatric diagnoses and the use of specific psychotropic medications. One resident was administered divalproex and quetiapine without corresponding care plan interventions, and another resident with schizoaffective disorder lacked a care plan problem for this diagnosis. The absence of these care plans was confirmed by the MDS nurse assistant, contrary to facility policy.
Two residents did not receive appropriate respiratory care when staff failed to follow a physician's order for oxygen administration for one resident and provided oxygen to another resident without a physician's order. Both residents were cognitively intact and had respiratory diagnoses requiring oxygen therapy, but staff did not adhere to facility policy or provider directives regarding oxygen flow rates and order verification.
A resident with end-stage renal disease on hemodialysis did not receive prescribed Sevelamer on multiple dialysis days because staff failed to send the medication or coordinate with the dialysis center, resulting in missed doses as documented in the MAR.
A resident with advanced age, acute kidney failure, morbid obesity, and weight fluctuations did not receive a required quarterly nutritional assessment from the RD, despite facility policy mandating such reviews at least quarterly. The RD was present in the facility but did not assess the resident, and staff confirmed this omission was not in line with established procedures.
A resident with a history of CVA and hemiplegia was admitted on hospice and required substantial assistance for mobility, but did not receive an initial therapy screening for rehabilitative services as required by facility policy. Staff interviews revealed that hospice residents were not being screened for rehab needs, despite policy stating all residents should be screened upon admission.
Staff failed to follow infection control protocols, including hand hygiene during medication administration for multiple residents, proper use of PPE when entering a resident's isolation room, and timely replacement of overfilled sharps containers on medication carts. These actions were not in accordance with facility policies and were acknowledged by staff during interviews.
The facility failed to respond promptly to call lights, affecting four residents with no mental impairments. Despite their conditions, including metabolic encephalopathy, anemia, multiple sclerosis, and Parkinson's disease, residents reported significant delays in assistance, ranging from 30 minutes to an hour. The facility's policy for timely response was not followed, as acknowledged by the administrator.
The facility failed to follow its garbage disposal policy when two outdoor dumpsters were left open, as observed during an inspection. The policy requires dumpsters to be closed to prevent attracting pests, which could pose a health risk to the 100 clinically compromised residents.
A facility failed to notify a resident's responsible party about blisters on the resident's hand, as required by policy. The resident, diagnosed with Alzheimer's and dementia, lacked decision-making capacity, necessitating family involvement. An LVN admitted forgetting to inform the resident's wife, and the DON confirmed the oversight, acknowledging the policy requirement for prompt notification of significant condition changes.
Failure to Document Resident Sign-Out for Overnight Pass
Penalty
Summary
The facility failed to follow its policy and procedure for signing residents out when a resident left the premises on an overnight pass. According to the facility's policy, all residents leaving the premises must be signed out and signed back in upon return. Record review and staff interviews revealed that there was no documentation or log available to confirm that the resident was properly signed out or signed back in, despite staff statements that this is standard protocol. The administrator acknowledged that the sign-out sheet could not be located, and the Director of Nursing could not recall if the resident had been signed out at the time of the incident. The resident involved had multiple medical diagnoses, including gout, hypertension, muscle contracture, a history of falls, major depressive disorder, anxiety, and a previous stroke with aphasia. Physician orders permitted the resident to go out on a therapeutic pass with family, and departmental notes indicated the resident left with family via wheelchair. However, the absence of the required sign-out documentation meant the facility did not ensure compliance with its own procedures for tracking residents leaving and returning to the facility.
Failure to Assess, Supervise, and Safely Manage Resident Smoking Activities
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to resident smoking practices. Multiple residents were not assessed for smoking upon admission, and quarterly smoking assessments were not completed as required by facility policy. Several residents who smoked were not identified on the facility's Smoker Worksheet, and their smoking status was not properly documented or evaluated. In addition, care plans for residents who smoked were not updated to reflect current assessments or to address safe storage, supervision, and use of smoking materials. Residents were observed smoking unsupervised in designated areas and in proximity to others using supplemental oxygen, despite facility policies prohibiting such practices. Several residents in possession of lighters also had active physician orders for supplemental oxygen, significantly increasing the risk of fire. Staff interviews confirmed that residents were allowed to keep their own cigarettes and lighters, and that supervision during smoking activities was not consistently provided. Some staff expressed concerns about the safety of allowing residents to possess lighters, especially near those using oxygen, but these concerns were not addressed in practice. Record reviews revealed that the facility did not inventory or document the presence of lighters upon admission, and that the care plans for residents who smoked were outdated or incomplete. The facility's policies required smoking assessments on admission and quarterly, as well as individualized care plans for smoking residents, but these were not followed. The lack of proper assessment, supervision, and safe storage of smoking materials placed residents at risk of serious harm, including fire hazards and burns, as directly observed and documented by surveyors.
Removal Plan
- Conduct a thorough and complete smoking assessment for all residents who smoke in the facility.
- Implement a new smoking screening assessment which screens the resident for safety and capability to participate in smoking activities.
- Secure all lighters from smoking residents and ensure lighters are kept in a locked box located in the medication room.
- Monitor and supervise the residents during smoking activities, with staff responsible for securing and distributing lighters.
- Update the admission process to include admitting nurse to interview and assess the resident for smoking and complete the smoking assessment.
- Update the Medication Administration Record for residents who are identified smokers so licensed nurses can monitor and observe residents who smoke.
- Update the care plans for all smoking residents.
- In-service all staff on the facility's smoking policy and procedures and safety measures related to smoking.
- Meet with all residents who are identified as smokers to inform them regarding the new protocol with disposable lighters. The disposable lighters will be in possession of the facility instead of residents who smoke.
- Continuously monitor the designated smoking area by staff to ensure that any residents who are smoking are smoking in a safe manner and no changes of condition are taking place. A monitoring log will be filled out by the staff member and kept on file for further evaluation and review.
Failure to Follow Food Safety and Sanitation Standards in Dietary Services
Penalty
Summary
Surveyors observed multiple failures to adhere to food safety and sanitation standards in the facility's kitchen. A container of parsley flakes and two unopened bags of bread were found to be past their best buy dates, and the Dietary Services Supervisor (DSS) confirmed these items should have been discarded according to facility policy. Additionally, food debris was found on the floor under the stove and the large food mixer, which was acknowledged by the DSS as not meeting cleanliness expectations. A scoop was also found improperly stored on top of a grains and cereal container, rather than in its designated clean container, contrary to facility policy. Further, wet trays were observed stacked together without being air dried, which the DSS stated was not in compliance with facility procedures. Review of the facility's policies and the 2022 FDA Food Code confirmed that equipment and utensils are required to be air dried after cleaning and sanitizing. These deficiencies were identified through direct observation, interviews with the DSS, and review of facility policies, indicating lapses in following established food safety and sanitation protocols.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey when two dumpsters located across the parking lot had lids that were not completely closed and were overflowing with multiple bags of trash. The Maintenance Supervisor acknowledged that the trash should not be overflowing and that the lids should be fully closed. During a review of the facility's policy and procedure on food-related garbage and refuse disposal, it was confirmed that the policy requires outside dumpsters to be kept closed and free of surrounding litter. The Administrator also confirmed that the facility was not in compliance with this policy, as the dumpster lids were not closed all the way. Additionally, the 2022 FDA Food Code was reviewed, which requires outside receptacles to have tight-fitting lids or covers.
Failure to Provide and Document Written Information on Advance Directives
Penalty
Summary
The facility failed to provide written information regarding the right to formulate an Advance Directive to nine out of ten sampled residents. Record reviews for these residents showed that while each had an Advance Directive Acknowledgement form indicating they understood they were not required to have an Advance Directive to receive care, the forms were incomplete and lacked documentation that written information about Advance Directives was actually provided. Additionally, reviews of the residents' POLST forms confirmed that these residents did not have Advance Directives on file. During interviews and record reviews, the Social Services Designee (SSD) stated that she explained the purpose of Advance Directives and POLST forms to residents or their responsible parties at admission and offered written materials about Advance Directives. However, the SSD acknowledged that she only documented this process on the Advance Directive Acknowledgement form and did not document elsewhere. Upon review, the SSD verified that the forms for the affected residents were incomplete and did not show evidence that written information had been provided. The facility's policy required that upon admission, residents be given written information about their right to accept or refuse medical treatment and to formulate an Advance Directive. The policy also required staff to document the offer of assistance and the resident's decision regarding Advance Directives in the medical record. The lack of complete documentation and evidence that written information was provided constituted the deficiency identified in the report.
Failure to Complete Admission MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely completion of the comprehensive admission Minimum Data Set (MDS) assessments for two residents. For both residents, review of their admission records and MDS documentation revealed that the required comprehensive admission MDS assessments were not completed and submitted by the federally mandated deadline. Specifically, the MDS Section Z - Assessment Administration for each resident was incomplete, and the RN Assessment Coordinator's signature verifying assessment completion was missing. The MDS Nurse Assistant confirmed during interviews that the assessments were not submitted by their respective due dates. This deficiency was identified through interviews and record reviews, which showed that the assessments for both residents were overdue. The lack of timely completion of these assessments had the potential to delay the care planning process necessary to meet the residents' comprehensive and individualized care needs, as required by federal regulations.
Failure to Develop Individualized Care Plans for Residents with Psychiatric Diagnoses and Medications
Penalty
Summary
The facility failed to develop individualized care plans for two residents, resulting in deficiencies related to the management of their medical and psychiatric needs. For one resident, there was no care plan addressing the use of divalproex, prescribed for poor impulse control, and quetiapine, prescribed for schizoaffective disorder with visual hallucinations. Despite these medications being administered as ordered, the care plan did not include problems, goals, or interventions related to their use, nor did it address necessary monitoring for side effects and behaviors. The Minimum Data Set Nurse Assistant (MDSNA) confirmed that care plans should have been developed for these medications and that their absence meant staff lacked guidance on monitoring the resident appropriately. Another resident with an active diagnosis of schizoaffective disorder did not have a care plan problem developed for this condition. The MDSNA verified that each diagnosis should be addressed in the care plan to ensure staff are informed on how to care for and monitor the resident's individualized needs. The facility's policy requires care plans to incorporate goals and objectives for each resident's highest level of independence, but this was not followed in these cases.
Failure to Follow Physician Orders and Obtain Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to two residents by not adhering to physician orders and established procedures for oxygen administration. For one resident with a diagnosis of chronic obstructive pulmonary disease (COPD), staff were observed administering oxygen at 1 liter per minute (LPM) via nasal cannula, despite an active physician's order specifying 2 LPM. This discrepancy was confirmed by both nursing and medical records staff, and the facility's policy indicated that oxygen should be administered at the ordered rate. The resident was cognitively intact and had a care plan directing staff to provide oxygen as indicated by provider orders. For a second resident with a history of acute respiratory failure with hypoxia, staff were observed administering oxygen at 5 LPM via nasal cannula without a physician's order in place at the time of observation. The absence of a physician's order for oxygen administration was confirmed by medical records staff, and the facility's policy required verification of a physician's order prior to oxygen administration. The resident was also cognitively intact and independent, with a care plan later reflecting the need for oxygen as needed for shortness of breath and low oxygen saturation.
Failure to Administer Dialysis-Related Medication as Ordered
Penalty
Summary
The facility failed to provide necessary dialysis-related care for a resident with end-stage renal disease who required hemodialysis three times per week. The resident had a physician's order for Sevelamer, a medication to control phosphorus levels, to be administered with meals on dialysis days. Review of the Medication Administration Record (MAR) showed that the medication was not given on multiple dialysis days, with staff documenting the resident as 'absent from home without meds.' Both a registered nurse and a licensed vocational nurse confirmed that the medication was not administered as ordered when the resident left for dialysis. Facility policy required staff education on medication timing for dialysis patients and agreements with the dialysis provider to ensure proper care coordination, including medication administration. However, staff interviews revealed that the facility did not send the medication with the resident or communicate with the dialysis center to ensure the medication was given, resulting in missed doses on several occasions.
Missed Quarterly Dietitian Assessment for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that a resident's nutritional and dietary needs were met when the Registered Dietitian (RD) did not complete the required quarterly assessment. A resident with a history of weight fluctuations, advanced age, acute kidney failure, and morbid obesity was receiving Lasix for fluid retention. The last nutritional assessment for this resident was completed on November 27, 2024, and the next quarterly assessment was due before the end of February 2025. However, the RD did not assess the resident during this period, despite being present in the facility in early March. Interviews with facility staff, including the Dietary Services Supervisor and the Quality Assurance Nurse, confirmed that the facility's policy requires the RD to assess residents on admission, quarterly, annually, and as needed. Review of the facility's policies further supported this expectation, stating that the RD is responsible for assessing nutritional needs and reviewing care plans at least quarterly. The failure to complete the quarterly assessment for this resident was acknowledged by staff as not following facility policy.
Failure to Screen Hospice Resident for Rehabilitative Services Upon Admission
Penalty
Summary
The facility failed to obtain an initial screening for rehabilitative services for one resident upon admission. The resident, who had a history of cerebrovascular accidents (CVA) and hemiplegia, was admitted with significant mobility limitations and required substantial to maximal assistance for mobility, as documented in the MDS. The resident expressed a desire to regain strength and function in the affected limbs and reported performing exercises several times a week. Despite these needs and the presence of orders for the use of an omni cycle, there were no orders for rehabilitative therapy, and no therapy screening was completed upon admission. Interviews with facility staff revealed that residents admitted on hospice were not being assessed or screened for rehabilitative services, with the Director of Rehab stating that such services for hospice residents were provided by the hospice facility. However, a review of the facility's policy indicated that a therapy screen should be completed upon admission for all residents, regardless of hospice status. The Director of Rehab confirmed that the required screening was not performed for this resident, in violation of facility policy.
Failure to Implement Infection Control and Prevention Measures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in several observed instances. During medication administration, a nurse did not perform hand hygiene at multiple required points, including after sanitizing equipment, before and after touching residents, and before and after administering medications. This occurred with three different residents, including one who required blood glucose monitoring and insulin administration. The nurse acknowledged awareness of the facility's infection control policies but did not adhere to them during these procedures. In another instance, a certified nurse assistant entered the room of a resident on Contact Isolation Precautions without donning gloves or a gown and did not perform hand hygiene after assisting the resident with personal items. The resident had an active physician's order for contact isolation due to bacteremia. The CNA confirmed knowledge of the policy requiring PPE and hand hygiene but did not follow these protocols during the observed interaction. Other staff interviews confirmed the expectation for PPE use and hand hygiene when entering and exiting isolation rooms and after contact with residents or their belongings. Additionally, two medication carts were found with sharps containers filled past the full line indicator, contrary to facility policy, which requires containers to be replaced when 75% to 80% full. Staff responsible for the carts acknowledged that the containers should have been replaced. The facility's policy and procedures for sharps disposal were not followed, as confirmed by the quality assurance nurse.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to adhere to its policy and procedure for timely response to call lights, affecting four residents. Each resident, despite having no mental impairment as indicated by their Brief Interview for Mental Status (BIMS) scores, reported significant delays in receiving assistance. Resident 1, diagnosed with metabolic encephalopathy, experienced instances where staff mistakenly assumed he was asleep and turned off the call light without checking his needs. Resident 2, with anemia, reported waiting at least 30 minutes for assistance, occurring at least once daily. Resident 3, diagnosed with multiple sclerosis, experienced wait times of 45 minutes to an hour. Resident 4, with Parkinson's disease, also reported delays of up to an hour. The facility's policy, titled 'Answering the Call Light' and dated March 2021, was not followed, as acknowledged by the facility administrator. The policy's purpose is to ensure timely responses to residents' requests and needs, which was not met in these cases. The administrator admitted that staff needed to respond more promptly to call lights, indicating a systemic issue in the facility's response protocol that jeopardized the health and safety of the residents involved.
Improper Garbage Disposal
Penalty
Summary
The facility failed to adhere to its food-related garbage disposal policy when two outdoor dumpsters were left open. This was observed during an inspection on November 23, 2024, at 1:20 p.m., when the surveyor, accompanied by the Director of Staff Developer, noted that the dumpsters were not closed. The facility's policy, dated October 2017, requires that outside dumpsters be kept closed and free of surrounding litter. Additionally, the FDA Federal Food Code, 2022, emphasizes the importance of proper storage and disposal of garbage to prevent attracting pests. This oversight had the potential to attract vermin, posing a significant health risk to the 100 clinically compromised residents residing in the facility.
Failure to Notify Responsible Party of Resident's Condition Change
Penalty
Summary
The facility failed to adhere to its policy regarding the notification of changes in a resident's condition. Specifically, a Licensed Vocational Nurse (LVN) did not inform the responsible party of blisters observed on the right hand of a resident diagnosed with Alzheimer's and dementia. The resident's medical records indicated that they lacked the capacity to understand and make decisions due to dementia, necessitating the involvement of a responsible party in their care decisions. Despite this requirement, the LVN admitted to forgetting to notify the resident's wife, who was listed as the responsible party. The Director of Nursing (DON) acknowledged the oversight and confirmed that the facility's policy mandates prompt notification of the resident's representative in the event of significant changes in the resident's physical condition. The facility's policy, dated February 2021, clearly states that a nurse should notify the resident's representative of any significant changes in the resident's condition. This failure to communicate the change in the resident's condition had the potential to exclude the family from participating in the resident's care plan.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Bernardino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waterman Canyon Post Acute | 0.2 mi | ★★★★★ | 2 | 0 |
| Medical Center Convalescent Hospital | 0.2 mi | ★★★★★ | 13 | 0 |
| Arrowhead Springs Healthcare | 0.4 mi | ★★★★★ | 0 | 0 |
| Haven Post Acute | 1.4 mi | ★★★★★ | 1 | 0 |
| Del Rosa Villa | 1.7 mi | ★★★★★ | 14 | 0 |
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