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 Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to timely notify resident representatives of significant changes in condition and events. In one case, a resident without decision-making capacity had worsening back pain, but only the resident was informed and the HCS was not notified. In another case, a resident who fell had an MPOA listed along with an alternate contact, yet only one unsuccessful attempt was made and the alternate was not contacted. A third resident experienced behavioral changes leading to a straight cath urine collection, and the POA was notified only after the procedure; the same resident later had a fall where the physician was notified that evening but the POA was not informed until the next morning. The DON acknowledged that these notifications were not completed or not done in a timely manner per policy.
Surveyors identified multiple failures to keep the environment free of hazards and to follow safe transfer and fall-prevention practices. Hazardous bleach wipes were left within reach at a bedside, loose drywall and debris were present in a bathroom and in dining room cabinets accessible to residents, and a topical medication was left at a bedside for self-use despite the resident not being care planned to self-administer. One resident care planned as dependent on a mechanical lift with two staff was repeatedly transferred to the toilet via wheelchair with one staff and no lift, while the resident reported staff often refused to assist to the bathroom and directed use of briefs or a bedpan instead. Another resident designated as a gait belt transfer was moved from bed to wheelchair by a NA without a gait belt, a resident care planned for a low bed with a fall mat had the bed left above the lowest position, and a resident assessed for total lift transfers had a bedside commode in the room despite the DON stating such residents should not have one.
A resident with Alzheimer's disease experienced two significant changes in condition, including elevated heart rate and altered mental status with multiple symptoms, but the facility did not notify the resident's representative as required by policy. The DON and Administrator confirmed that notification should have occurred.
The facility was found to have medicated items and personal hygiene products left accessible in resident rooms, posing potential hazards to wandering residents. Items such as hydrogen peroxide, anti-fungal powder, and oral pain relief rinse were not properly labeled or stored, as confirmed by the DON and CRN.
The facility failed to ensure residents received treatment and care according to professional standards, care plans, and resident choices. Issues included unavailable medication, undocumented insulin administration, and discrepancies in advanced directive orders, affecting multiple residents.
The facility failed to ensure a safe environment by leaving a resident's medication unattended and having multiple instances of unlocked and unattended medication and treatment carts. These lapses in supervision and security were observed by surveyors and confirmed by staff.
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents during an annual survey. Both residents had signed the Notice of Medicare Non-Coverage (NOMNC) but did not receive the SNF ABN form, placing them at risk of not being informed of their rights and potential liability for services not covered by Medicare.
The facility failed to report an alleged incident of verbal abuse to the appropriate state agencies. A nurse informed a resident about her need for a shower due to an odor in front of other residents, which was perceived as humiliating. The incident was investigated internally but not reported as required by the facility's Abuse Prohibition Policy.
The facility failed to ensure accurate MDS assessments for three residents, including significant weight loss for one resident and incorrect discharge statuses for two others. These inaccuracies were acknowledged by the facility's Administrator.
The facility failed to complete new PASARRs for three residents with newly evident or possible serious mental disorders, including delusional disorder, Bipolar disorder, and PTSD. The oversight was confirmed by staff during interviews.
The facility failed to update the care plans for two residents when their needs changed. One resident's care plan did not include her delusional disorder diagnosis, and another resident's care plan did not address her significant pain management needs or her goals for pain relief, despite her worsening condition and recent changes in pharmacological interventions.
The facility failed to evaluate and document the effectiveness of pain medication for two residents. An LPN signed out and administered oxycodone but did not document its effectiveness, as confirmed by the Clinical Operation Lead.
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were reviewed and signed by the attending physician. For a resident, the pharmacist recommended reassessment of the A1C goal and potential initiation of Januvia, but there was no evidence that the physician reviewed or acted on this recommendation, as the MRR was not signed.
The facility failed to obtain routine and/or emergency dental services for a resident who had a loose tooth. Despite an active order for a dental referral, no referral had been made, as confirmed by the Interim Director of Nursing.
The facility failed to maintain appropriate infection control procedures during a medication pass for a resident. An LPN was observed removing pills from a blister pack with ungloved hands after touching the medication cart doors and over-the-counter pill bottles with bare hands. The administrator was informed and expressed surprise, acknowledging that handling pills with soiled bare hands was against common-sense practices.
Failure to Timely Notify Resident Representatives of Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ representatives in a timely manner when there was a change in condition, as required by the facility’s “Change in Condition: Notification of” policy. For one resident who lacked medical decision-making capacity, documentation showed a change in condition with worsening lower back pain, and only the resident was notified while the designated Health Care Surrogate (HCS) was not informed. For another resident with a fall, the Change in Condition form documented an attempt to contact the Medical Power of Attorney (MPOA) without success, but there was no documented attempt to contact the alternate MPOA/emergency contact listed in the resident’s profile. A third resident experienced multiple events where the Power of Attorney (POA) was not notified in a timely manner. In one instance, a change in condition with behavioral symptoms led to a urine specimen being obtained via straight catheterization; documentation showed the POA was notified after the procedure had already been completed, and the resident’s son reported he had been present earlier that day and was not informed at that time. In another instance, the same resident had a fall, and while the physician was notified the same evening, documentation showed the POA was not notified until the following morning. In each case, the DON confirmed that the notifications to the MPOA/POA/HCS were either not made or not made in a timely manner according to the documentation and facility policy.
Failure to Maintain Safe Environment and Follow Transfer and Fall-Prevention Protocols
Penalty
Summary
The deficiency involves multiple failures to maintain an environment free of accident hazards and to provide adequate supervision and safe practices to prevent accidents. In one room, a container of bleach cleaning wipes was left unattended and within reach at a resident’s bedside, with no measures in place at the time to prevent resident access. In another room, loose drywall above a bathroom sink was observed with chunks and pieces falling into the sink, and this condition remained unrepaired on recheck several days later. A resident was also found with a medicine cup containing a white creamy substance identified as Bio-Freeze left on the bedside table, even though the resident was not care planned to self-administer medications. Additional environmental hazards were identified in the Transitional Care Unit dining room, where sheet rock chunks approximately 1/2 inch in size, sawdust piles, and small wood splinters were present in all lower kitchen cabinets to the right and left of the sink and in the island cabinets, all easily accessible to residents. Several deficiencies related to unsafe transfer practices and toileting were also documented. One resident’s lift transfer evaluation and care plan specified dependence on a mechanical lift with two staff for transfers and toileting, yet documentation showed that over a one-month period the resident was assisted to the toilet via wheelchair with one staff and without use of the mechanical lift. The resident reported that most staff would not assist with transfers to the bathroom and instead told the resident to use a brief or bedpan, despite the resident’s stated ability to transfer with assistance and use grab bars. Other transfer-related deficiencies included an observed transfer where a nurse aide assisted a resident from bed to wheelchair by holding under the resident’s arm and pivoting the resident into the wheelchair without using a gait belt, even though the resident was designated as a gait belt transfer. Another resident who was care planned for fall prevention with a fall mat at the bedside and the bed in the lowest position was observed with the fall mat in place but the bed not in the lowest position. For a different resident, a lift assessment required use of a total lift with full body sling for transfers, yet a bedside commode was present in the room, and the DON stated that a resident using a total lift should not have a bedside commode in the room. These observations collectively demonstrate failures to follow established safety measures, care plans, and transfer requirements intended to prevent accidents and falls.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of two significant changes in the resident's condition. According to interviews and record review, the resident, who had been determined by a physician to lack capacity due to Alzheimer's disease, experienced two separate incidents: one involving an elevated pulse/heart rate while resting, and another involving altered mental status, weakness, shortness of breath, nausea, vomiting, and lethargy. In both cases, the resident remained in the facility and was treated in-house by on-call physicians, but the representative was not informed of these events. The resident's representative reported not being contacted by the facility regarding either incident and expressed distress over the lack of communication. Review of facility policy confirmed that the representative should have been notified immediately of significant changes in the resident's physical or mental status. The Director of Nursing and the Administrator acknowledged that the notifications should have occurred.
Unsafe Storage of Medicated Items in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, as evidenced by the presence of medicated items left accessible to residents with wandering tendencies. During a complaint survey, it was observed that various rooms contained medical items and personal hygiene products that were not labeled or stored securely, making them easily accessible to wandering residents. Specifically, items such as hydrogen peroxide, anti-fungal powder, no-rinse foam cleanser, and oral pain relief rinse were found in residents' rooms without proper identification or secure storage. The survey identified that 25 residents had wandering tendencies, and the facility census was 121. The presence of these items posed potential risks, as indicated by the Safety Data Sheets (SDS) and Material Safety Data Sheets (MSDS) provided by the Director of Nursing (DON), which outlined hazards such as eye irritation, inhalation risks, and ingestion dangers. During an interview, the Corporate Registered Nurse (CRN) confirmed that medicinal items should not be present in residents' rooms, highlighting a lapse in the facility's supervision and safety protocols.
Failure to Follow Physician Orders and Resident Care Plans
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices. Resident #49's medication, Tizanidine HCl 2 mg tablet, was not available for three consecutive days, and the LPN was instructed to hold the medication until it arrived from the pharmacy. The Director of Nursing (DON) acknowledged the issue, attributing it to pharmacy staffing problems and logistical delays. Resident #33 did not receive insulin as ordered for elevated blood sugar levels. The Medication Administration Record (MAR) showed a blood sugar level of 435, but there was no documentation that insulin had been administered. The interim DON confirmed that the MAR did not reflect any medication being given. Additionally, the facility failed to follow the Physician Orders for Scope of Treatment (POST) forms for Resident #125, who had a DNR order that was not followed, and for Resident #26, whose physician orders for skin integrity and fracture stability were not adhered to. The facility also had discrepancies in advanced directive orders for Resident #71 and Resident #44, where the orders did not match the POST forms. Resident #71 had conflicting physician orders for advanced directives, and the care plan was not updated to reflect the correct order. Similarly, Resident #44 had an active physician's order for CPR and other interventions that did not match the POST form. These failures had the potential to affect more than a limited number of residents, as indicated by the facility census of 129.
Unattended and Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards, as evidenced by multiple observations of unattended and unsecured medication and treatment carts. On 04/08/24, a surveyor observed a Spiriva inhaler left unattended on a resident's over-the-bed table. The resident confirmed that the nurse had left it there in the morning, and the charge nurse verified that the medication should not have been left at the bedside. The resident had an order for the inhaler but did not have an order for it to be left at the bedside, indicating a lapse in proper medication management. Additionally, on 04/15/24, a surveyor found an unlocked and unattended medication cart on the 300 Hall. The LPN responsible for the cart acknowledged the issue and locked it upon the surveyor's request. Similarly, on 04/09/24, a treatment cart was observed unlocked and unattended by the South Nurses Station. The LPN responsible for the treatment cart also locked it after being notified by the surveyor. These incidents demonstrate a pattern of inadequate supervision and failure to secure medication and treatment carts, posing potential risks to residents.
Failure to Provide SNF ABN Forms
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents during an annual survey. Resident #28 began Medicare Part A skilled services on 10/18/23, with the last covered day being 11/10/23. Although the Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 11/08/23, there was no evidence that a SNF ABN form had been provided and signed. Similarly, Resident #19 began Medicare Part A skilled services on 02/20/24, with the last covered day being 03/21/24. The NOMNC was signed and dated on 03/19/24, but again, there was no evidence that a SNF ABN form had been provided and signed. In an interview conducted on 04/10/24, the Administrator acknowledged the facility's failure to provide the SNF ABN forms to both residents prior to their last covered day of Medicare Part A skilled services. This oversight placed the residents at risk of not being informed of their rights and potential liability for services not covered by Medicare. The review of the Form Instructions for the SNF ABN Form CMS-10055 (2018) indicated that Medicare requires these forms to be issued to beneficiaries prior to providing care that Medicare may not pay for because it is either not medically reasonable and necessary or considered custodial.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the appropriate state agencies. The incident occurred when a nurse informed a resident about her need for a shower due to an odor in front of other residents, which was perceived as humiliating and derogatory. The resident reported the incident to the Nursing Home Administrator (NHA), who, along with the Director of Nursing (DON), investigated the grievance and re-educated the nurse involved. However, the incident was not identified as verbal abuse and was not reported to the state agencies as required by the facility's Abuse Prohibition Policy. The incident was corroborated by another resident who witnessed the event and described it as embarrassing and derogatory. The facility's grievance log and state reportable log were reviewed, revealing that the incident was documented but not reported as verbal abuse. The Administrator confirmed that the incident had not been reported to the state agencies, explaining that the specific words indicating verbal abuse were not used during the initial report. This failure to report the incident as verbal abuse constitutes a deficiency in the facility's compliance with state regulations.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. Resident #116 experienced a significant weight loss of 12.5% over 3.5 months, which was not accurately reflected in the MDS. The Registered Dietician (RD) incorrectly marked the weight loss section based on a misunderstanding that weight loss should not be recorded if the resident had not been in the facility for six months. This resulted in an inaccurate assessment of the resident's nutritional status and potential care needs. Additionally, the facility inaccurately coded the discharge status for two other residents. Resident #126 was discharged home, but the MDS incorrectly indicated a discharge to a short-term general hospital. Similarly, Resident #124 was transferred to the emergency room due to clinical acuity, but the MDS incorrectly coded the discharge status as home/community. These inaccuracies were acknowledged by the facility's Administrator during interviews, highlighting a failure in the proper completion and review of MDS assessments.
Failure to Complete New PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for residents with newly evident or possible serious mental disorders. This deficiency was identified for three out of seven residents reviewed under the PASARR category during the Long-Term Care Survey Process. Resident #44 had a diagnosis of delusional disorder added on 04/21/20, but the facility did not complete a new PASARR upon the resident's readmission from hospitalization. Additionally, the care plan for Resident #44 was not revised to reflect the changes. The Social Worker acknowledged the oversight during an interview on 04/10/24. Resident #49 was admitted with a Bipolar diagnosis effective from 09/09/21, but the only PASARR on file was dated 11/20/2018, which did not address the Bipolar diagnosis. The Social Worker confirmed the absence of a new PASARR for this diagnosis. Similarly, Resident #81's PASARR did not include diagnoses of Bipolar disorder or Post-Traumatic Stress Disorder (PTSD), despite these conditions being present. The Administrator and Social Worker confirmed the missing information during interviews conducted on 04/09/24.
Failure to Revise Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to revise the care plans for two residents when their needs changed. Resident #44's care plan was not updated to include her diagnosis of delusional disorder, which was added to her medical record on 04/21/20. The Social Worker acknowledged that the PASRR was incorrect and had not been completed prior to the resident's readmission from hospitalization, and the care plan had not been revised to reflect these changes. Resident #71's care plan did not address her pain management needs, despite her reporting significant pain and a recent change in her pharmacological pain interventions. The care plan also failed to include her goals for pain relief and did not reflect her worsening condition, including a diagnosis of cancer with a chest mass and lymph node involvement. During an interview, Resident #71 rated her pain as 10/10 and expressed that her pain goal was 0/10, but these details were not incorporated into her care plan. The Clinical Reimbursement Coordinator acknowledged that the care plan had not been updated or revised to reflect the resident's goals and recent changes.
Failure to Document Pain Medication Effectiveness
Penalty
Summary
The facility failed to effectively evaluate the pain level and the effectiveness of pain medication for two residents. For one resident, a Licensed Practical Nurse (LPN) signed out an oxycodone tablet and documented its administration on the Medication Administration Record (MAR). However, there was no documentation showing the effectiveness of the pain medication. This was confirmed by the Clinical Operation Lead (COL). The failure to document the effectiveness of the pain medication was noted during a record review and confirmed by staff.
Failure to Ensure Physician Review of Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were reviewed and signed by the attending physician. This deficiency was identified for one of five residents reviewed during the Long-Term Care Survey Process. Specifically, for Resident #6, the pharmacist completed an MRR on 12/26/23, recommending reassessment of the existing A1C goal and potential initiation of Januvia 25 mg daily, with close monitoring of glucose levels. However, there was no evidence that the attending physician reviewed or acted on this recommendation, as the MRR was not signed by the physician. This was confirmed during a staff interview with the Clinical Operation Lead on 04/15/24.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to obtain routine and/or emergency dental services for Resident #75. During an interview, the resident indicated she had a loose tooth. A record review revealed an active order dated 02/07/24 for a dental referral for a loose cap on the upper front tooth, but no referral had been made. The Interim Director of Nursing confirmed that there was no dental referral in the resident's chart.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to maintain appropriate infection control procedures during a medication pass for Resident #49. During an observation, an LPN was seen removing pills from a blister pack with ungloved hands after touching the medication cart doors and over-the-counter pill bottles with bare hands. The medications involved were Gabapentin 100 mg capsule, Lisinopril 2.5 mg tablet, and Oyster Shell 500/200 mg tablet. The administrator was informed of the issue and expressed surprise, indicating that the LPN had reported the medication pass went well and acknowledged that handling pills with soiled bare hands was against common-sense practices.
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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 South Charleston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Valley Of Journey | 2.2 mi | ★★★★★ | 2 | 0 |
| Dunbar Center | 2.4 mi | ★★★★★ | 4 | 0 |
| Thomas Hospitals Skilled Nursing Unit | 6.3 mi | ★★★★★ | 0 | 0 |
| Arthur B Hodges Center, The | 6.4 mi | ★★★★★ | 0 | 0 |
| Complete Care At Oak Ridge Llc | 7.5 mi | ★★★★★ | 0 | 0 |
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