Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Pointe Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Unsafe Water Temperatures in Shared Bathrooms: Water in two shared bathrooms repeatedly exceeded safe limits, reaching 153 F to 167 F when tested at the hottest setting. One bathroom had a warning sign that water may exceed 120 F, while the other did not during the initial observation. A resident reported the water got very hot and took about five minutes to cool to a tolerable temperature, and an LPN/CNA stated the water could cause burns. The facility policy required resident-area tap water to stay at or below 120 F.
Dialysis competency deficiencies were identified for four residents with ESRD or CKD who depended on hemodialysis and had AV fistulas or a Port-a-Cath. An LVN stated she had not received facility competency training on dialysis care, another LVN said she checked for bruit but not thrill, and the IP/DSD was unaware of thrill assessment. The DON confirmed the Port-a-Cath could not be assessed for bruit and thrill, yet the LVN documented both on the resident’s pre-dialysis assessment.
Medication administration times were not followed or accurately documented for two residents. An LVN gave scheduled anticoagulant and antiplatelet medications about 90 minutes early, then charted them as if they were given at the ordered time. The residents had significant neurologic and feeding-tube-related diagnoses, and the DON confirmed the times were outside the prescriber’s order and not documented accurately.
Medication Storage and Labeling Deficiencies: Medications and biologicals were stored improperly in a medication refrigerator and on a med cart, with rectal suppositories, ophthalmic drops, insulin, tuberculin, and pre-filled COVID-19 vaccine syringes kept together instead of separated by route. Four vaccine syringes were also stored without the original labeled container. An LVN/NS, DSD/IP, and DON stated the items should have been stored separately and that the vaccine syringes needed original manufacturer labeling with expiration information.
Kitchen food safety and sanitation practices were not followed when TCS foods were not documented on the cool down log, a staff member's beard restraint did not cover facial hair, wet hotel pans were stacked instead of air dried, the food prep sink lacked backflow prevention, and multiple items in a resident refrigerator were unlabeled and undated. The RD and MS confirmed the observed conditions, and facility policy and USDA Food Code requirements were reviewed during the investigation.
Improper Disposal and Containment of Refuse: The outdoor dumpster was observed overflowing with trash, with the lid propped open and dirty gloves and food waste scattered around the bin. The recycling area also had overflowed cardboard boxes and other recyclables placed on the ground next to the container, and the RD noted the area had a foul odor and was not sanitary.
Infection control failures were observed involving a resident’s exposed CPAP and nebulizer masks, another resident’s nasal cannula found on the floor, and an LPN who entered an EBP room and performed g-tube and blood sugar care without the required gown and gloves. Staff also stored personal belongings in the laundry room, creating a cross-contamination concern.
A resident with rib fractures and continuous O2 therapy was observed receiving oxygen at 3 to 4 LPM even though the physician order and care plan called for 2 LPM via nasal cannula. Staff records showed conflicting telephone orders were transcribed within minutes, and the DON stated the resident should only have received the ordered rate and that the LVN should not have requested a change without a change in condition.
A resident with diagnoses including intracerebral hemorrhage and cognitive communication deficit had a daily Breo Ellipta order for suspected COPD, but the inhaler was not available during the scheduled med pass. The LVN confirmed the inhaler had not been reordered in time, said the pharmacy should have been notified when the supply was low, and stated the missed dose was a med error. The DON stated nursing staff were expected to reorder meds timely and follow up with the pharmacy when a medication was unavailable or running low.
Medication Error Rate Exceeded Threshold: Surveyors found a 6.45% medication error rate during a med pass observation, with an LVN failing to administer a resident’s scheduled Breo Ellipta inhaler because it had not been reordered timely and missing a scheduled aspirin dose. The resident had a history of stroke with hemiplegia, hemiparesis, and cognitive communication deficit, and the DON stated staff were expected to timely reorder meds and follow prescriber orders.
Ice Machine Not Sanitized Per Manufacturer Instructions: The MS was observed cleaning the ice machine with a Clorox bleach-type solution instead of the manufacturer-specified Manitowoc-approved cleaner and sanitizer. The MS stated he cleaned the machine monthly using the Clorox solution, and the facility policy required ice machines and ice storage containers to be drained, cleaned, and sanitized per the manufacturer’s instructions.
A resident with respiratory conditions was found in a room with a dust-covered ceiling vent, peeling paint, and a task light cord that was out of reach. The resident reported difficulty due to these conditions, and facility records showed no recent maintenance had been performed to address these issues, contrary to facility policy.
Surveyors found multiple deficiencies in medication storage and labeling, including expired eyedrops, medications for discharged residents left in storage, an unlabeled insulin vial, mismatched medication card directions, loose unidentified tablets in a medication cart, and suppositories for discharged residents not disposed of as required. Staff interviews and policy reviews confirmed these lapses in proper medication management.
Surveyors found that food preparation utensils and equipment were not cleaned or maintained in good condition, including a toaster with burned residue, a damaged knife handle, a soiled can opener, overcrowded drying utensils, and dirty baking pans and oven. These failures in kitchen sanitation and equipment maintenance placed 44 residents at risk for foodborne illness.
Surveyors observed that a specimen refrigerator containing biological samples was stored in the medication storage room directly below the medication refrigerator. Both an LVN and the DON confirmed this practice, and the DON acknowledged the risk of infection due to potential contamination of medications with specimen samples. This practice did not align with the facility's infection prevention and control policy.
A resident with dysphagia, hemiplegia, and dementia was assisted with eating by an OT who stood while spoon-feeding, contrary to facility policy and staff expectations that require meal assistance to be provided at eye level to maintain dignity. Both the DON and DOR confirmed that staff should be seated when assisting residents with meals.
A resident with moderate cognitive impairment who required assistance with personal care was allowed to smoke outside the facility without a safe smoking evaluation, care plan, or use of a smoking apron. Staff confirmed the absence of a smoking schedule and proper disposal methods, with cigarette butts discarded on the ground. Facility policy required assessment and care planning for smoking safety, which was not completed.
The facility did not provide the required minimum of 80 square feet per resident in several multi-occupancy rooms, as confirmed by direct measurement. Despite this, observations showed that residents and staff could move safely and no negative outcomes were noted.
Unsafe Water Temperatures in Shared Resident Bathrooms
Penalty
Summary
The facility failed to ensure water temperatures were maintained within a safe range in two Jack-and-[NAME] bathrooms shared by five sampled residents. During observations, faucet water in the bathroom shared by Residents 45, 59, and 60 reached 154.1 F when turned to the hottest setting, and the bathroom shared by Residents 1 and 40 reached 153.2 F when tested the same way. On follow-up testing in the bathroom shared by Residents 1 and 40, the water reached 167.4 F in less than 10 seconds, and when retested with the faucet adjusted to the middle position, it still measured 155 F. The Maintenance Director stated the water temperatures in both bathrooms were not acceptable and not safe for residents' use. Resident 1 was admitted in March 2026 with a diagnosis of Alzheimer's disease. Resident 40 was admitted in May 2024 with a diagnosis of neurofibromatosis. Resident 45 was admitted in March 2026 with a diagnosis of COPD, Resident 59 was admitted in April 2026 with visual loss in both eyes, and Resident 60 was admitted in April 2026 with a diagnosis of NSTEMI. In the bathroom shared by Residents 45, 59, and 60, a posting near the sink stated water may exceed 120 F, but no such posting was present in the bathroom shared by Residents 1 and 40 during the initial observation. Resident 45 stated the water in the bathroom could get very hot and took about five minutes to cool to a tolerable, non-burning temperature before use, making hand washing difficult because of the time required to obtain safe water. CNA 2 stated the safe water temperature for resident use was between 110 F and 120 F and that the bathroom water could cause burns. The facility policy stated tap water should be kept within a temperature range to prevent scalding and that water heaters serving resident areas should be set to no more than 120 F or the maximum allowable state temperature.
Dialysis Competency Deficiencies in Access Site Assessment
Penalty
Summary
The facility did not demonstrate competency in dialysis care for four dialysis-dependent residents, including residents with end-stage renal disease, chronic kidney disease, diabetes mellitus, and access sites consisting of AV fistulas or a Port-a-Cath. One resident had a Port-a-Cath in the right upper chest, while the other three residents had AV fistula access sites in the left upper arm. The facility assessment identified four residents dependent on hemodialysis and included staff training and competencies for specialized care such as dialysis. During interviews, LVN 2 stated she had been employed for three months and had not received competency training on dialysis care and management from the facility. LVN 2 also stated she routinely assessed the resident with the Port-a-Cath before dialysis. LVN 3 stated she cared for two dialysis-dependent residents and checked the access site for bruit using a stethoscope before sending them to dialysis, but was unaware of checking for thrill and said she could only recall receiving dialysis care training in nursing school. The Infection Preventionist/Director of Staff Development stated that when assessing a dialysis AV fistula site, staff should check for bruit, but did not mention checking for thrill and was unable to recall when dialysis training was last provided. The DON confirmed the resident with the Port-a-Cath was the only resident with that type of access and that a Port-a-Cath cannot be assessed for bruit and thrill because it is under the skin. The DON also confirmed the last competency training for licensed nurses was on 5/5/25. Record review showed LVN 2 documented bruit and thrill present for the resident with the Port-a-Cath on pre-hemodialysis assessment forms, including on 5/1/26, despite the access being located in the right upper chest and not assessable for bruit and thrill.
Medication Administration Times Not Followed or Accurately Documented
Penalty
Summary
The facility did not ensure medications were administered in accordance with physician orders for two sampled residents when licensed nursing staff gave scheduled medications approximately 90 minutes earlier than the ordered administration time and then documented inaccurate administration times. Resident 1 was admitted in March 2026 with diagnoses including metabolic encephalopathy, Alzheimer’s disease, and gastrostomy status. Resident 5 was admitted in April 2023 with diagnoses of hemiplegia and hemiparesis following cerebral infarction and encounter for attention to gastrostomy. On 4/28/26, an LVN stated she had already completed medication administration for Resident 1 and Resident 5 before 8:11 a.m. During the medication pass observation, the LVN was observed administering medications to another resident from 8:11 a.m. through 8:51 a.m. The MAR showed Resident 1’s 9:00 a.m. medications, including clopidogrel bisulfate 75 mg and heparin sodium 5000 units/mL, were documented as given at 8:13 a.m., and Resident 5’s 9:00 a.m. apixaban 5 mg via PEG tube was documented as given at 8:14 a.m. The observed timeline was inconsistent with the documented times. During interview, the LVN stated she started giving medications to Resident 1 and Resident 5 as early as 7:30 a.m. because of a morning staff huddle, despite the ordered 9:00 a.m. administration time. She stated the facility required medications to be given within the prescribed timeframe and that giving medications outside that timeframe and documenting inaccurate times was a medication error. The DON stated medication administration times should be documented accurately for continuity of care and that giving medications outside the prescribed timeframe was not in accordance with the physician’s order. The facility policy stated medications are to be administered in accordance with prescriber orders, within one hour of the prescribed time, and documented with the date and time administered.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage and labeling practices. During observation and interview in the medication room, the first-level compartment of the medication refrigerator contained a tray with medications of different routes stored together, including bisacodyl rectal suppositories, ophthalmic solution eye drops for Residents 1, 2, and 40, an opened box of pre-filled COVID-19 vaccine syringes, an opened box of tuberculin injectable solution, and Resident 2's insulin vials. On the second compartment, four pre-filled COVID-19 vaccine syringes were stored in an opened blister pack tray without a labeled container. The LVN/Nursing Supervisor stated the medications should have been stored separately by route and that the vaccine syringes should have remained in a labeled container with the original manufacturer labeling and expiration date information. During a separate observation and interview in Medication Cart #1, the first drawer's farthest right compartment contained a zip-lock bag with Resident 3's rectal suppositories stored together with multiple oral pill medications. The DSD/Infection Preventionist stated the rectal suppositories should have been stored separately from the oral medications. The DSD/IP also stated that storing medications with different routes together increased the risk of cross-contamination and medication administration errors, including the potential for rectal suppositories to be administered by the wrong route. Resident 1 was admitted with metabolic encephalopathy and glaucoma. Resident 2 was admitted with end stage renal disease and type 2 diabetes mellitus with retinopathy. Resident 3 was admitted with hemiplegia and hemiparesis following cerebral infarction and had gastrostomy status. Resident 40 was admitted with lagophthalmos of the left eye and dry eyes syndrome. The DON stated that all medications must be stored according to their designated route of administration, and the facility policy stated medications and biologicals are to be stored in the packaging in which they are received, with medications stored in an orderly manner and external-use medications stored separately from other medications.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
Food safety and sanitation guidelines were not followed in the kitchen when the cool down process for time/temperature control for safety foods was not monitored. During a concurrent observation and interview in the kitchen, tuna salad and egg salad labeled with a preparation date of 04/26/2026 were found in the reach-in refrigerator, and the Registered Dietitian stated the cool down log was in use. The two items were not included on the cool down log, and the RD stated they should have been monitored and documented on the log. The USDA Food Code 2022 cooling requirements were reviewed during the investigation. Additional kitchen sanitation concerns were observed. A staff member was seen with a beard guard below the chin and not covering facial hair, and the RD confirmed staff are expected to wear beard restraints in the kitchen. Four hotel pans were observed stacked and stored wet, and the RD stated equipment should be air dried and not stored wet. The food preparation sink was observed without backflow prevention, and the Maintenance Supervisor stated the sink did not have backflow prevention. In the resident refrigerator in the rehabilitation gym, multiple food items were found unlabeled and without dates, including canned fruit, Jello, a reusable container, and probiotic cultured drink bottles; the RD stated items should be labeled with the resident's name and use-by date.
Improper Disposal and Containment of Refuse
Penalty
Summary
The facility failed to ensure proper disposal and containment of refuse. During observation with the Registered Dietitian, the outdoor dumpster near the facility was seen with its lid propped open because trash inside the container was overflowing. Dirty gloves and food waste were scattered on the ground beneath and around the dumpster, and the area had a strong foul odor. The recycling area was also observed with overflowed cardboard boxes and other recyclables placed on the ground next to the recycling container. During interview, the RD stated that bacteria could form in the dumpster, that keeping it open was not sanitary, and that it could attract rodents, flies, and other insects. The facility policy stated that garbage and refuse containers are to be properly contained with lids or otherwise covered and that disposal areas are to be maintained free from odors and waste fats to prevent pests.
Infection Control Failures With Respiratory Equipment, EBP Care, and Laundry Storage
Penalty
Summary
The facility failed to implement infection prevention and control practices for respiratory equipment used by a resident with COPD, RSV, and obstructive sleep apnea. Resident 45’s care plan directed staff to follow infection control protocol and universal/standard precautions. During observation, the resident’s CPAP mask was left exposed on top of the CPAP machine without a protective bag, and the resident stated the facility had not provided a bag for storage when the mask was not in use. On a later observation, the CPAP mask remained exposed, and the resident’s nebulizer mask was also observed exposed on the tray table without protective storage. Staff interviews confirmed the equipment should have been kept in a bag to prevent exposure to dirt, contaminants, and insects. A CNA stated environmental services staff may have touched or moved the masks during cleaning, which could have contaminated the equipment. An LVN stated licensed nurses were responsible for cleaning the CPAP and nebulizer masks weekly and that leaving them exposed increased the risk for the resident to inhale contaminants. The IP also stated that if CPAP and nebulizer masks were not in use, they should have been placed in a bag. The facility also failed to handle another resident’s oxygen equipment appropriately. Resident 59, who had visual loss in both eyes and giant cell arteritis, had a care plan that directed staff to follow infection control protocol and universal/standard precautions. During observation, the resident’s nasal cannula was found lying on the floor next to the oxygen concentrator and shoes. The resident stated nurses assisted with applying and removing the cannula at night because the resident was blind and needed help. An LVN observed the cannula on the floor and stated it should have been discarded because it had touched the floor. The IP stated the cannula should have been discarded and replaced with a new one, and that respiratory masks and cannulas not in use should have been placed in a bag. The facility further failed to follow enhanced barrier precaution requirements for a resident with a g-tube and foley catheter. Resident 3’s care plan required EBP during high-contact care activities, including device care and feeding tube use. An EBP posting outside the room indicated staff must wear gloves and a gown for high-contact resident care activities. An LVN entered the room carrying supplies and began care without donning the required PPE, then performed a blood sugar check, turned off the tube feeding machine, retrieved a stethoscope, exposed the resident’s abdominal area, disconnected the g-tube from the feeding machine, and checked tube feeding residual without wearing the required PPE. The LVN stated she was in a hurry and forgot to wear proper PPE. The IP and DON stated PPE was required in the EBP room and that wearing PPE was intended to protect residents from infection. The facility also failed to keep staff personal belongings out of the laundry area. During observation, a housekeeping/laundry staff member’s purse, items inside a green disposable plastic bag, and a black jacket were stored on a chair in the laundry room. The maintenance director stated staff belongings should be stored in the staff lounge to prevent cross-contamination. The IP/DSD stated personal belongings should not be stored in the laundry room and that lockers were provided in the breakroom for staff use.
Oxygen Administered Above Physician Order
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards for one sampled resident who was receiving continuous oxygen therapy. Resident 72 was admitted with diagnoses that included multiple rib fractures and a history of fall, and the care plan directed staff to administer oxygen at 2 L via nasal cannula and monitor for signs of hypoxia. During observation on 4/27/26 and again on 4/28/26, the resident was found in bed with oxygen running at 3 LPM, then 3.5 LPM, and later 4 LPM, despite the resident stating the order was for 2 LPM. A PTA initially stated the resident was receiving 2 LPM, then confirmed the concentrator was actually set at 4 LPM and later clarified the order as 2-4 LPM. Record review showed the physician order dated 4/24/26 was for oxygen at 2 LPM via nasal cannula continuously with oxygen saturation monitoring every shift. Telephone orders transcribed on 4/28/26 showed multiple changes within 12 minutes, including discontinuing the 2 LPM order, starting 2-4 LPM, restarting 2 LPM, and then discontinuing the 2-4 LPM order. The DON stated the resident should only receive the oxygen rate ordered by the physician and that the resident was placed at risk by receiving a higher oxygen rate than ordered. The DON also stated the LVN should not have requested a change when there was no change in condition.
Delayed Availability of Routine Inhalation Medication
Penalty
Summary
The facility failed to provide pharmaceutical services and procedures to ensure the timely acquisition, dispensing, and administration of a routine inhalation medication for one resident. Resident 49 was admitted with diagnoses including nontraumatic intracerebral hemorrhage and cognitive communication deficit, and had a physician order for Breo Ellipta inhalation aerosol powder, 1 puff daily at 9:00 a.m. for suspected COPD. During a medication administration pass observation, the scheduled inhaler was not available for administration, and the LVN stated it was not available for the resident's use. A follow-up review of the electronic MAR showed the Breo Ellipta inhaler had not been reordered in a timely manner and was reordered the same day it was found unavailable. The LVN stated the pharmacy should have been notified when the inhaler was running low or when approximately six puffs remained, and that routine medications should always have been available in the medication cart. The LVN also stated the missed dose would be considered a medication error. The DON stated licensed nursing staff were expected to reorder medications timely and follow up with the pharmacy when medication was unavailable or running low.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure medication error rates remained below 5 percent. During a medication pass observation, surveyors identified 2 errors out of 31 opportunities, resulting in a 6.45 percent medication error rate. One sampled resident, admitted in February 2026 with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage and a cognitive communication deficit, was observed receiving scheduled medications from an LVN on 4/28/26. During the observation, the LVN prepared the resident’s oral medications and a lidocaine patch, but the resident’s Breo Ellipta inhaler was unavailable for administration because it had not been reordered timely. The resident’s MAR also showed that the scheduled 9:00 a.m. aspirin 81 mg dose was not given. In follow-up interviews, the LVN stated the inhaler should have been reordered when it was running low and acknowledged that failure to administer the aspirin was a medication error. The DON stated staff were expected to timely reorder medications and follow up with the pharmacy when medications were unavailable or running low. The facility policy stated medications are to be administered in a safe and timely manner and in accordance with prescriber orders.
Ice Machine Not Sanitized Per Manufacturer Instructions
Penalty
Summary
The facility failed to maintain the ice machine in safe operating condition by not sanitizing it according to the manufacturer’s instructions. During observation and interview on 04/27/2026 at 3:05 PM, the Maintenance Supervisor was seen using a Clorox bleach-type solution to clean the ice machine, even though the manufacturer specified a Montauk-type descaler solution. The ice machine had been professionally cleaned the day before and appeared clean and in good condition, but the cleaning chemical being used did not match the manufacturer’s required method. During review of the manufacturer’s maintenance protocol and the facility’s policy on 04/27/2026, it was noted that USDA Food Code 2022 Section 4-601.11 requires equipment food-contact surfaces and utensils to be clean to sight and touch. The Maintenance Supervisor stated he cleaned the ice machine once a month using a Clorox cleaning solution and demonstrated an internal cleaning process that did not follow the manufacturer’s required procedure. The manufacturer’s guidance for the Manitowoc ice machine required use of an approved cleaner and sanitizer, and the facility policy stated that ice machines and ice storage containers are to be drained, cleaned, and sanitized per the manufacturer’s instructions.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for a resident with significant respiratory conditions, including acute respiratory failure, COPD with acute exacerbation, and asthma. During an observation and interview, it was found that the resident's room had a ceiling air vent covered with dust, scattered areas of peeling paint on the wall, and a task lighting cord that was not long enough for the resident to reach. The resident reported that her respiratory conditions could be aggravated by inhaling dust and paint particles and expressed a preference to operate the task light independently, which she was unable to do due to the short cord. A review of the facility's preventive maintenance log revealed that no maintenance activities, such as wall patching or repainting, had been performed in the resident's room for several months. The Maintenance Director confirmed responsibility for identifying and completing necessary repairs but acknowledged the lack of recent maintenance in this area. Facility policies require the provision of a safe, clean, and comfortable environment, including adequate lighting and building maintenance, but these standards were not met in this instance.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to medication storage and labeling within the facility. One resident's Latanoprost eyedrops were found stored in the medication cart beyond the 42-day use-by date, despite clear labeling on the medication box and confirmation from both the MDS Coordinator and the DON that the medication should have been discarded after the specified period. Additionally, six vials of Retacrit, a medication for anemia, were found in the medication room refrigerator belonging to a resident who had been discharged several days prior. The DON confirmed that medications for discharged residents should be disposed of on the day of discharge to prevent medication errors. Further observations revealed an opened and unlabeled Lispro insulin vial in the medication room refrigerator. The LVN and DON both stated that insulin vials should be labeled with the resident's name and the date opened. During medication administration, a nurse gave a resident Metoclopramide from a medication card with directions that did not match the current physician's order. The nurse stated she followed the physician's order, but the DON acknowledged that the medication card should have been updated to reflect the change in directions. Additional deficiencies included the discovery of 18 loose, whole tablets scattered underneath medication cards in a medication cart, which staff could not identify and stated should be disposed of according to policy. Suppositories belonging to two discharged residents were also found in the medication cart, despite facility policy requiring immediate disposal of such medications upon discharge. These findings were corroborated by interviews with nursing staff and a review of facility policies regarding medication labeling, storage, and disposal.
Unsanitary Food Storage and Equipment Maintenance
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and serving of food in a safe and sanitary manner. Specifically, a two-slot toaster was found with hardened, black, burned particles resembling bread crumbs on its surface and between its slots and bottom. A knife stored in a wall-mounted rack had a silicone handle that was warped, jagged, and dented. An industrial can opener mounted on a preparation table had a black or dark brown sticky substance on its blade and in the crevices of the feed wheel. Additionally, a plastic container under a preparation table was overcrowded with utensils such as spatulas, scoops, measuring spoons, whisks, ladles, and tongs, preventing proper air drying. Further observations included newly washed muffin pans, baking trays, and baking sheets that were stacked while still wet, with visible burnt surfaces, stains, dents, and deep scratches. The interior of the industrial oven was soiled with a buildup of burnt grease and food particles. These conditions were confirmed during interviews and were not in accordance with the facility's own policy and the 2022 Federal Food Code, which require food-contact surfaces to be clean to sight and touch and equipment to be maintained in good repair. These failures placed 44 residents who received food from the kitchen at risk for foodborne illnesses or illnesses related to contaminated utensils.
Specimen Refrigerator Improperly Stored in Medication Room
Penalty
Summary
The facility failed to follow infection control procedures by storing a specimen refrigerator, containing biological samples such as stool and urine specimens, in the medication storage room directly below the medication refrigerator. This arrangement was observed during a visit with an LVN, who confirmed that the specimen refrigerator had been in the medication storage room for an extended period, though she could not recall when it was first placed there. The presence of biological specimens in the same area as medications was directly observed, with both types of refrigerators in close proximity. Further observation and interview with the DON confirmed the continued storage of the specimen refrigerator in the medication room, with the DON acknowledging the risk of infection spread due to the potential for contaminating medications with resident specimen samples. Review of the facility's Infection Prevention and Control Program policy indicated that the program is intended to prevent the development and transmission of communicable diseases and infections, but the observed practice did not align with these requirements.
Undignified Meal Assistance Provided by Standing Staff Member
Penalty
Summary
During a meal observation, a resident with diagnoses including dysphagia, hemiplegia, and dementia was assisted with eating by an occupational therapist (OT) who stood while spoon-feeding the resident. The resident was seated in a wheelchair in the dining room at the time. The OT stated that she sometimes stood and sometimes sat while feeding residents, depending on the cues she needed to provide. The resident had a physician's order for 1:1 feeding, indicating the need for dedicated, personalized support during meals. Interviews with the Director of Nursing (DON) and the Director of Rehabilitation (DOR) confirmed that staff are expected to be seated at eye level with residents when providing meal assistance to preserve dignity and ensure safety. The facility's policy on meal assistance also specifies that residents who cannot feed themselves should be assisted with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents while feeding them. The observed action of standing while feeding the resident was inconsistent with both facility policy and staff expectations, resulting in undignified and disrespectful treatment.
Failure to Assess and Plan for Safe Smoking Practices
Penalty
Summary
The facility failed to provide a safe environment for a resident who was a known cigarette smoker. Upon review of the resident's admission record, it was found that the resident had diagnoses including weakness and required assistance with personal care. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 8, was observed to go outside the facility to smoke twice daily, accompanied by staff. Both RNs and a CNA confirmed that the resident did not use a smoking apron during these smoke breaks, and there was no ash tray available, resulting in cigarette butts being discarded on the ground. There was also no established smoking schedule for the resident. Further investigation revealed that there was no safe smoking evaluation or care plan in place for the resident, as confirmed by the MDS Coordinator. The facility's own policy required an evaluation of smoking status upon admission, including the ability to smoke safely, and mandated that any restrictions or concerns be documented in the care plan. The lack of a safe smoking evaluation and care plan for this resident constituted a failure to follow facility policy and created a potential risk for burn injury to the resident and danger to others.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple occupancy rooms for 10 out of 45 residents. Specifically, rooms 19, 20, and 21 each contained four beds, but measured only 432 square feet per room, resulting in 73.56 square feet per bed, which is below the required standard. This was confirmed by the Maintenance Director through direct measurement. Observations conducted over several days did not reveal any negative outcomes or safety concerns related to the reduced space, and staff and residents were able to move about safely and without obstruction.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Castro Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Bay Post-acute | 0 mi | ★★★★★ | 34 | 0 |
| Baywood Court Health Center | 1 mi | ★★★★★ | 0 | 0 |
| Kaiser Permanente Post-acute Care Center | 1.2 mi | — | 0 | 0 |
| St John Kronstadt Convalescent Center | 1.3 mi | ★★★★★ | 13 | 0 |
| Canyon Creek Post-acute | 1.3 mi | ★★★★★ | 2 | 0 |
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