SAN BERNARDINO, CA - Valley Healthcare Center received an immediate jeopardy citation during a March 2025 federal inspection for allowing smoking residents to possess cigarettes and lighters while smoking unsupervised, creating serious fire safety risks.
Critical Fire Safety Failures Lead to Immediate Jeopardy
The most serious violation at Valley Healthcare Center involved unsafe smoking practices that posed immediate danger to residents. Inspectors found the facility failed to ensure safe smoking practices when smoking residents possessed smoking materials and smoked without supervision.
The facility also failed to conduct required smoking assessments on admission and quarterly to identify smokers and monitor their activities. Additionally, individualized care plans addressing smoking activities were not developed for residents who smoked.
Federal inspectors called an immediate jeopardy situation in the presence of facility administrators on March 4, 2025, at 6:53 p.m., requiring an immediate corrective action plan.
Immediate Safety Measures Implemented
The facility submitted a preliminary corrective action plan on March 6, 2025, which included comprehensive safety measures. All lighters were secured from smoking residents and kept in a locked box in the medication room, with staff responsible for distributing and supervising their use.
The facility conducted thorough smoking assessments for all residents who smoke and implemented new screening procedures to evaluate residents' safety and capability to participate in smoking activities. Continuous monitoring of the designated smoking area was established every half hour by staff to ensure safe smoking practices.
The immediate jeopardy was lifted on March 6, 2025, at 4:15 p.m., after facility administrators verified implementation of corrective measures through observation and record review.
Respiratory Care Violations Compromise Patient Safety
The inspection also revealed failures in respiratory care affecting two residents. The facility failed to follow physician's orders for oxygen administration and failed to obtain proper physician's orders for oxygen therapy.
One resident with chronic obstructive pulmonary disease (COPD) was receiving oxygen at 1 liter per minute instead of the ordered 2 liters per minute. The resident had been admitted in December 2024 with COPD and had no cognitive impairment, making proper oxygen delivery essential for breathing comfort.
A second resident was observed using oxygen at 5 liters per minute without any physician's order for oxygen administration. Medical records confirmed no order existed for this resident's oxygen therapy until March 4, 2025, when a new order was finally obtained.
Proper oxygen therapy is critical for residents with respiratory conditions. Insufficient oxygen flow can lead to shortness of breath, decreased blood oxygen levels, and potential respiratory complications. The facility's own policy requires verification of physician's orders before oxygen administration.
Medication Management Failures in Dialysis Care
A resident receiving dialysis three times per week experienced medication administration failures that could impact kidney disease management. The resident's prescribed Sevelamer medication, used to control high blood phosphorus levels in dialysis patients, was not administered on several dialysis days.
Medication records showed the resident did not receive Sevelamer on February 27, March 1, March 4, and March 6, 2025. Nursing staff documented these missed doses as "absent from home without meds," indicating the facility failed to send required medications with the resident to dialysis.
Sevelamer helps prevent dangerous phosphorus buildup in dialysis patients' blood. Missing doses can lead to serious complications including bone disease, cardiovascular problems, and mineral imbalances that are particularly dangerous for patients with end-stage renal disease.
Infection Control Lapses Create Cross-Contamination Risks
Multiple infection control violations were documented throughout the facility. Nursing staff failed to perform proper hand hygiene during medication administration for three residents, including during insulin administration and blood glucose testing.
One Licensed Vocational Nurse was observed administering medications without performing hand hygiene before and after patient contact. During insulin administration, the nurse removed one glove to retrieve supplies while keeping the other glove on, then continued the procedure without proper hand hygiene.
A Certified Nurse Assistant entered a room of a resident on contact isolation precautions without wearing required gloves and gown. The resident was isolated due to active bacteremia, requiring personal protective equipment to prevent infection spread.
Two medication cart sharps containers were found filled past the safety line indicators, creating needlestick injury risks. Proper sharps disposal is essential to prevent bloodborne pathogen transmission among staff and residents.
Food Safety and Sanitation Concerns
Kitchen inspections revealed multiple food safety violations that could lead to foodborne illness. Expired food items were found in storage, including parsley flakes past their February 23, 2025 best-buy date and two bags of bread expired on February 26, 2025.
Food debris was discovered on floors under kitchen equipment, including the stove and large food mixer. Wet trays were stacked together without proper air-drying, violating sanitation protocols designed to prevent bacterial growth.
A serving scoop was improperly stored on top of a grain container rather than in designated clean storage areas. These violations increase contamination risks for vulnerable nursing home residents who may have compromised immune systems.
Nutritional Assessment and Rehabilitation Service Gaps
The facility failed to provide required quarterly nutritional assessments for at least one resident. A registered dietitian had not assessed one resident since November 27, 2024, missing the required February 2025 quarterly review.
Regular nutritional assessments are especially important for residents with conditions like kidney failure and morbid obesity, as documented in this resident's medical history. Proper dietary monitoring helps prevent malnutrition and manages chronic health conditions.
Additionally, the facility failed to provide initial rehabilitation screening for a hospice resident who expressed desire to regain strength and function in his left arm and leg following stroke-related paralysis. While hospice patients may have different goals, federal regulations still require assessment of rehabilitation needs upon admission.
Waste Management and Environmental Safety Issues
External waste management violations were documented when dumpsters were found overflowing with trash bags and lids not properly closed. Open dumpster lids and overflow create pest attraction risks and potential disease transmission pathways.
Proper waste containment is essential in healthcare facilities to prevent rodent and insect infestation that could carry pathogens into resident living areas.
Regulatory Context and Industry Standards
These violations represent failures across multiple critical areas of nursing home operations. Immediate jeopardy citations are reserved for the most serious situations where resident safety is at immediate risk.
The smoking violations are particularly concerning given the vulnerability of nursing home residents, many of whom have mobility limitations that could prevent escape during fire emergencies. Respiratory care failures can be life-threatening for residents with COPD and other breathing conditions.
Infection control violations take on heightened significance in congregate living settings where infectious diseases can spread rapidly among vulnerable populations.
The March 2025 inspection findings at Valley Healthcare Center demonstrate the importance of comprehensive regulatory oversight in ensuring nursing home residents receive safe, appropriate care across all aspects of daily operations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Healthcare Center from 2025-03-07 including all violations, facility responses, and corrective action plans.
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