The Director of Nursing at Valley Healthcare Center told federal inspectors in January that Resident 64 had been found with marijuana and had told staff he was driving his car. She expressed concern for his safety when driving because of his substance use and the unresolved surgical wound.
But no care plan existed to address the resident's illegal drug use or his driving.
"The facility don't know how to keep Resident 64 safe when driving his car," the Director of Nursing told inspectors on January 20. She acknowledged that a care plan should have been developed to ensure his safety when using mind-altering substances and driving.
The facility's own policy, dated November 1, 2017, requires comprehensive person-centered care plans for each resident based on their individual needs. The plans must include measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs.
The Director of Nursing admitted the policy wasn't followed.
Valley Healthcare Center's care planning failures extended beyond the marijuana case. Inspectors found two other residents whose safety risks went unaddressed by formal care plans.
Resident 9 left the facility with his ex-wife on May 6, 2025, and didn't return until May 9 — a three-day absence that staff apparently didn't know about in advance. When inspectors asked for evidence of a care plan addressing the resident's pattern of leaving without informing staff, the Social Services Director couldn't provide one.
"There was no care plan written for non-compliance," the Social Services Director told inspectors on January 29.
The third case involved Resident 56, who had been prescribed Cresemba, a medication used to treat serious fungal infections. The resident started taking 186 milligrams twice daily on January 23, according to physician orders.
When inspectors asked the Infection Prevention Nurse for evidence of a care plan addressing the antifungal medication, she couldn't provide one either.
Federal regulations require nursing homes to develop individualized care plans that address each resident's specific needs and circumstances. The plans serve as roadmaps for staff to provide appropriate care and maintain resident safety.
At Valley Healthcare Center, that system broke down repeatedly. Three residents with distinct safety concerns — one using illegal drugs while driving, another leaving the facility without notice, and a third taking potent antifungal medication — all lacked the basic care planning required by federal law.
The facility's care planning policy specifically states its purpose: "To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs." It also requires plans to address any services that might be needed, including situations where residents exercise their right to refuse treatment.
The marijuana case presented particularly complex safety issues. Resident 64's combination of substance use, driving, and an unhealed foot wound created multiple risk factors that should have triggered immediate care planning. The Director of Nursing's admission that staff didn't know how to keep him safe while driving highlighted the facility's lack of preparation for such scenarios.
Resident 9's three-day disappearance raised different concerns about monitoring and communication. The fact that he left with his ex-wife suggests some level of planning, but the absence of any care plan to address his tendency to leave without informing staff left the facility unprepared to ensure his safety or track his whereabouts.
The antifungal medication case involved medical complexity that also warranted specialized attention. Cresemba treats serious fungal infections and can have significant side effects and drug interactions. Without a care plan addressing the medication's use, staff lacked guidance on monitoring requirements and potential complications.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to a few residents. The inspection occurred following a complaint, suggesting someone had raised concerns about the facility's care planning practices.
The deficiencies violated federal tag F656, which governs comprehensive care planning requirements. This regulation mandates that nursing homes develop detailed, individualized plans that address each resident's full range of needs and circumstances.
Valley Healthcare Center's failures left three residents without the systematic attention their situations required, creating gaps in safety oversight that federal regulators deemed unacceptable for a facility entrusted with vulnerable residents' care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Healthcare Center from 2026-01-29 including all violations, facility responses, and corrective action plans.