Valley Manor Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on two of four units. Specifically, the facility failed to:-Ensure staff used personal protective equipment (PPE) when performing care for residents who were on enhanced barrier precautions (EBP); and, -Ensure staff wore PPE when handling dirty linen.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide care to each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for four (#3, #6, #55, #61) of eight residents reviewed of 36 sample residents. Specifically, the facility failed to respond to call lights in a timely manner to provide care with dignity for Resident #3, Resident #6, Resident #55 and Resident #61.

Inspectors wroteBased on observations, interviews and record review, the facility failed to keep medical information confidential for one (#20) of one resident out of 36 sample residents. Specifically, the facility failed to ensure Resident #20's medical information was not located in the state survey findings binder in the front lobby of the facility where the public had access to it.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were kept free from physical abuse for one (#7) of four residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to:-Protect Resident #7 from physical abuse by Resident #70; and,-Protect Resident #7 from physical abuse by Resident #64.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#21 and #44) of five residents were free from chemical restraints and were receiving the least restrictive approach for their needs out of 36 sample residents. Specifically, the facility failed to follow up on the pharmacist's recommendations for a gradual dose reduction recommendations (GDR) for Resident #21 and Resident #44 for two months.

Inspectors wroteBased on record review and interviews, the facility failed to timely report an allegation of abuse involving three (#43, #39 and #76) of five residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to-Timely report allegations of abuse by licensed practical nurse (LPN) #3 towards Resident #43;-Report allegations of abuse by LPN #3 towards Resident #39; and, -Report allegations of abuse by the occupational therapist (OT) towards Resident #76.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly and timely investigate an allegation of abuse involving two (#43 and #76) of five residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to:-Thoroughly investigate an allegation of abuse by licensed practical nurse (LPN) #3 towards Resident #43; and,-Thoroughly investigate an allegation of abuse by the occupational therapist (OT) towards Resident #76.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (#3) of three residents out of 36 sample residents. Specifically, the facility failed to: -Ensure Resident #3's brace was consistently implemented; and, -Ensure range of motion exercises were consistently completed for Resident #3's contracture.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#44) of four residents reviewed for accident hazards out of 36 sample residents. Specifically, the facility failed to protect Resident #44 from possible ingestion of medications left unattended on the medication cart.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure accurate assessments, informed risks, and ongoing monitoring was in place for one (#74) of three residents with bed rails out of 36 sample residents. Specifically, the facility failed to:-Ensure a bed rail safety assessment was completed prior to the bed rail placement on Resident #74's bed; and, -Ensure less restrictive measures were attempted prior to the use of bed rails for Resident #74.

Inspectors wroteBased on observations, record review and interviews, the facility to ensure residents were free from accidents or hazards for one (#1) of three residents reviewed for accidents out of three sample residents. Specifically, the facility failed to implement interventions to prevent an elopement for Resident #1, despite identifying the resident at high risk for elopement.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#17 and #39) of five residents out of 38 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being. Resident #17 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure and severe protein-calorie malnutrition. On 10/4/23, the resident weighed 137 pounds (lbs). On 10/25/23 the resident sustained a 5.8% (percent) (7.88 lbs) weight loss in 21 days, which was considered severe. After the resident sustained the weight loss the facility failed to implement additional nutritional interventions to address the resident's weight loss. [...]

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to act promptly upon the grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to effectively address, resolve and maintain a systematic approach to ongoing resident concerns of staff treatment towards residents that were brought up during resident council.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of three dining rooms and one of one kitchenette. Specifically, the facility failed to: -Ensure hand hygiene was offered and provided to residents during meal times; -Ensure staff plating ready-to-eat food used hand hygiene after touching potentially contaminated surfaces; and, -Ensure staff used hand hygiene before donning gloves to serve ready-to-eat food.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident's legal representative was provided an opportunity to exercise a right on behalf of the resident for one (#30) of five residents reviewed for resident rights out of 38 sample residents. Specifically, the facility failed to: -Ensure Resident #30's Medical Orders for Scope of Treatment (MOST) form was signed by the resident's medical durable power of attorney (MDPOA) instead of a family member who was not the resident's legal representative.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from abuse for two (#66 and #6) of five residents reviewed for abuse out of 38 sample residents. Specifically, the facility failed to: -Prevent Resident #6 from physically abusing Resident #66; -Update Resident #66 and Resident #6's care plans with effective interventions to prevent abuse; and, -Identify patterns or causes of resident-to-resident abuse.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#50) of three residents out of 38 sample residents Specifically, the facility failed to ensure staff used a gait belt appropriately for assistance and not to restrain a resident from getting out of her wheelchair.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being for two (#6 and #66) of six residents reviewed for dementia care out of 38 sample residents. Specifically, the facility failed to: -Effectively implement a meaningful activity program for Resident #6 and Resident #66 to prevent resident-to-resident abuse; and, -Implement person-centered interventions for Resident #6's and Resident #66's behaviors.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for two (#30 and #21) of five residents reviewed for medications out of 38 sample residents. Specifically, the facility failed to ensure as needed (PRN) psychotropic medications were discontinued after 14 days for Resident #30 and Resident #21.

Inspectors wroteBased on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure the residents'food was palatable in taste, texture, appearance and temperature.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on two of two units. Specifically, the facility failed to wipe down a shared mechanical lift and slings between residents.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to ensure dignified, respectful care for two (#8 and #14) of eight residents reviewed out of 23 sample residents. Resident #14 said she did not receive timely assistance from staff for bathing and other care needs, and as a result she felt lonely and disrespected, wanted to go home, and cried a lot. Resident #8 said she sometimes did not receive dignified, respectful care, and as a result experienced bowel incontinence and felt ashamed, embarrassed, mad and aggravated.

Inspectors wroteBased on interviews and record review, the facility failed to ensure six (#8, #111, #53, #52, #25 and #51) of eight residents reviewed were free from abuse, neglect and mistreatment out of 23 sample residents. Specifically, the facility failed to ensure: -Resident #8, who was dependent on staff assistance, was free from mistreatment involving rough transfers, and verbal/mental abuse after reporting mistreatment; -Resident #111, who was dependent on staff assistance, was free from neglect when requesting assistance from staff who refused to provide the assistance; -Resident #53, who was dependent on staff assistance, was free from verbal/mental abuse during dining; -Resident #52, who was dependent on staff assistance, was free from physical resident to resident altercations; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure effective preventive interventions to prevent pressure injuries for one (#13) of four residents reviewed for pressure injuries out of 23 sample residents. Resident #13 admitted to the facility with diagnosis of hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) and was identified by assessment to be at high risk for developing pressure injuries. The resident required extensive two-person assistance with bed mobility, transfers, toileting, and bathing. The facility failed to ensure preventative interventions were implemented which resulted in the resident sustaining a facility acquired unstageable pressure ulcer to Resident #13's foot. These failures led to the resident experiencing tenderness and pain in his left foot.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free of misappropriation of property for one (#26) of eight residents reviewed for misappropriation of property of 23 sample residents. Specifically, the facility failed to ensure a resident's credit card was not stolen and used by staff.

Inspectors wroteBased on record review and staff interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with State law involving one (#14) of eight residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to report allegations of physical abuse for Residents #14.

Inspectors wroteBased on record review and staff interviews, the facility failed to thoroughly investigate an allegation of sexual abuse involving one (#29) of eight residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to thoroughly investigate potential sexual abuse on 9/7/22 and failed to complete an investigation of potential abuse on 9/13/22 for Resident #29.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II was completed for one (#8) of two residents reviewed for PASARR out of 23 sample residents. Specifically, Resident #8's PASARR Level I assessment revealed a Level II was needed, but the facility failed to ensure it was completed, to ensure an appropriate plan of care was developed and care provided to meet the resident's needs.