MONTOURSVILLE, PA - Federal health inspectors cited Valley View Rehab and Nursing Center for multiple care deficiencies during a May 2025 inspection, including a critical delay in implementing infection control precautions that potentially exposed vulnerable residents to antibiotic-resistant bacteria.
Weekend Supervision Gap Allowed Infection Risk
The most serious violation involved a resident who tested positive for Vancomycin-Resistant Enterococcus (VRE) in late April 2025. Medical records show the resident's urine culture collected on April 23 revealed between 10,000-50,000 colony forming units per milliliter of enterococcus faecium VRE, a particularly concerning strain of antibiotic-resistant bacteria.
Two days later, on April 25, the attending physician documented the positive VRE result and initiated antibiotic treatment with Macrobid 100 milligrams twice daily for five days. However, contact precautions—the standard infection control protocol for VRE—were not ordered until April 27, a full four days after the positive culture result.
The infection preventionist confirmed to inspectors that nursing supervisors failed to implement the required contact precautions over the weekend, creating a window during which staff, other residents, and visitors could have been exposed to the antibiotic-resistant organism.
VRE represents a significant threat in nursing home environments. These bacteria have developed resistance to vancomycin, one of the antibiotics commonly reserved for treating serious infections. When VRE colonizes or infects vulnerable nursing home residents—many of whom have compromised immune systems or chronic health conditions—treatment options become extremely limited.
The organism spreads primarily through direct contact with an infected person or by touching contaminated surfaces and equipment. In healthcare settings, VRE can survive on surfaces for extended periods, contaminating bed rails, doorknobs, medical equipment, and other frequently-touched items. Each day without proper precautions increases the risk of transmission.
Contact precautions require healthcare workers to wear gloves and gowns when entering the resident's room and to use dedicated equipment that stays in the room. These measures create a barrier between the infectious organism and other residents, preventing the bacteria from spreading throughout the facility.
The two-day delay meant staff members likely entered and exited the resident's room without appropriate protective equipment, potentially carrying the bacteria on their hands or clothing to other residents' rooms. The facility's own policy, last reviewed in March 2025, explicitly requires contact precautions for residents infected or colonized with VRE.
This violation marked the second time in less than a year that federal inspectors cited Valley View Rehab for infection prevention and control deficiencies. The facility received a previous citation for similar issues in June 2024.
Dementia Care Plans Lacked Individualization
Inspectors also identified failures in care planning for residents with dementia, affecting at least two individuals reviewed during the survey.
One resident, admitted in November 2024 with a dementia diagnosis, received a care plan on December 3, 2024, titled "Impaired cognitive function/dementia or impaired thought processes related to Vascular Dementia." However, the care plan failed to include individualized interventions addressing the resident's specific cognitive needs and behavioral patterns.
A second resident, admitted in November 2022 with dementia added to her diagnoses in January 2023, had a care plan from August 2023 labeled "Impaired cognitive function/impaired thought processes, moderately impaired per BIMS; dementia with psychosis." Despite the notation of psychotic symptoms—a particularly challenging aspect of dementia care—the plan similarly lacked person-centered interventions.
Dementia affects each individual differently, with varying patterns of memory loss, confusion, behavioral changes, and functional decline. Effective dementia care requires assessment of the specific ways cognitive impairment affects each person's daily life, communication abilities, and behavioral patterns.
Person-centered care plans should identify triggers for confusion or agitation, successful communication strategies, meaningful activities that engage the resident, environmental modifications that promote safety and independence, and approaches for managing challenging behaviors without resorting to medications or restraints.
Generic care plans that simply note a dementia diagnosis without specifying individualized interventions fail to provide the nursing staff with actionable guidance for delivering appropriate care. This leaves residents vulnerable to inadequate responses to their cognitive and behavioral needs.
Dental Care Gap Despite Documented Need
The inspection revealed that one resident went without professional dental services despite documented evidence of decayed or broken teeth spanning more than a year.
The resident, admitted in May 2023, initially had Medicare coverage that transitioned to private payment in June 2023, then converted to Medicaid in May 2024. When admitted, the resident's daughter signed a form declining dental services—a decision made when the resident was not covered by Medicaid, which includes dental benefits.
Annual assessments completed in May 2024 and May 2025 both documented that the resident had "obvious or likely cavities or broken natural teeth." The May 2024 assessment indicated the facility would proceed to develop a care plan to address the dental issues, but no such care plan was ever created. The May 2025 assessment showed the facility decided not to proceed with a care plan at all.
The facility's own policy, reviewed in November 2024, requires that each resident receive at minimum an annual oral examination with a dentist and be offered dental services every six months as insurance allows. Medicaid coverage, which began in May 2024, would have covered professional dental services at no cost to the resident or family.
Despite three care conference meetings between November 2024 and May 2025—during which the resident's daughter participated either in person or by phone—facility records contained no evidence that staff informed her about the availability of dental services under her mother's new Medicaid coverage or offered to arrange such care.
When interviewed by inspectors on May 20, 2025, the resident's daughter stated she did not know when her mother last received professional dental care and said she "would love to see that happen."
Only after inspectors raised the issue did facility staff contact the daughter on May 22, 2025, to discuss dental services. The daughter immediately agreed and requested the consent forms be mailed for her signature.
Untreated dental decay and broken teeth create multiple health risks for nursing home residents. Pain from dental problems can interfere with eating, leading to inadequate nutrition and weight loss. Oral infections can spread to other parts of the body, potentially causing serious complications in medically fragile individuals. Difficulty chewing due to damaged teeth may cause residents to avoid nutritious foods or increase their risk of choking.
Regulatory Context
The deficiencies violated multiple federal and Pennsylvania state nursing home regulations. The infection control violation breached federal requirements for infection prevention and control programs and Pennsylvania regulations governing resident care policies and nursing services. The dementia care planning failures violated federal standards requiring appropriate treatment and services for residents with dementia. The dental care gap violated both federal dental services requirements and Pennsylvania dental services regulations.
Federal inspectors classified all violations as causing "minimal harm or potential for actual harm" and affecting "few" residents. However, the patterns identified—particularly the repeat infection control citation—raise questions about the facility's quality oversight systems.
Valley View Rehab and Nursing Center is required to submit a plan of correction detailing how it will address each deficiency and prevent future occurrences. The complete inspection report, including the facility's response, is available through the state survey agency.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley View Rehab and Nursing Center from 2025-05-23 including all violations, facility responses, and corrective action plans.
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