Valley View Manor Healthcare Center

Inspectors wroteBased on interview and document review the facility failed to ensure they had obtained and documented an informed consent, including an explanation of the risks and benefits of using a psychotropic medication or alternative treatment options for 1 of 5 residents (R4) sampled.

Inspectors wroteBased on interview and document review the facility failed to ensure a gradual dose reduction (GDR) was attempted, or a rationale was provided for 1 of 5 residents (R4) sampled.

Inspectors wroteBased on interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) for 1 of 5 residents (R8) who had new on-set of mental illness.

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate antibiotic use for 1 of 3 residents (R16), who were reviewed for antibiotic stewardship.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate interventions were in place to prevent elopement for 3 of 3 residents (R1, R4, R6) who were identified as an elopement risk. This resulted in immediate jeopardy (IJ) for R1 when she was able to leave the facility when it was dark and foggy outside and was able to walk 5-6 blocks away before being found, which put R1 at likelihood for serious harm or death. The IJ began on 4/13/26 when R1 was able to elope from the facility after the facility failed to complete a comprehensive assessment for individualized interventions and level of supervision after R1 removed, then refused, replacement of Wanderguard (personal alarming safety device) on 3/29/26 and continued to display exit seeking behaviors. [...]

Inspectors wroteBased on interview and document review the facility failed to develop a comprehensive person-centered Elopement care plan that included interventions to mitigate the risk of elopement for 1 of 1 resident (R1) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess falls for root cause, implement appropriate interventions and revise the care plan to prevent and/or reduce the risk for future falls for 2 of 3 residents (R2, R4) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for 2 when he sustained a head laceration following a fall and an IJ for R4 when after repeated falls sustained shoulder dislocation that had not identified since the last imaging that did not show dislocation on 7/30/25. The IJ began on 10/20/25 after R2 had a fall that resulted in head laceration, the facility failed to complete a comprehensive analysis and implement appropriate interventions which resulted in and/or could have mitigated the risk of subsequent falls. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to increase in resident falls and as needed (PRN) psychotropics being administered as a chemical restraint by developing and implementing action plans for process improvement. This had the potential to affect all 34 residents that resident in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed ensure residents were free from chemical restraints by not identifying duplicative antipsychotic therapy without appropriate indications, failed to identify target behaviors, failed to develop individualized non-pharmacological interventions, and failed to attempt and/or offer non-pharmacological interventions prior to the administration of as needed (PRN) doses of antipsychotic medications for 1 of 1 resident (R2) who had verbal and physical behaviors towards staff reviewed for falls.

Inspectors wroteBased on interview and document review the facility failed to ensure that alleged violations involving abuse/neglect were reported to the administrator and to the State Agency (SA) timely, in accordance with established policies for 1 of 1 resident (R5) reviewed for injury of unknown origin.

Inspectors wroteBased on interview and document review the facility failed to develop a comprehensive person-centered behavior care plan with individualized interventions for behavior management for 1 of 1resident (R2) with Alzheimer's Disease.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise the care plan for 2 of 3 residents (R2, R6) who were reviewed for falls and impaired skin integrity.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure treatments were used per standards of practice and only applied with a corresponding physician order for 2 of 2 residents (R5, R7) reviewed for non-pressure related skin concerns.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess and monitor an open blister and discoloration of skin on 1 of 1 resident (R5) and in addition failed to comprehensively assess and monitor a laceration for 1 of 1 resident (R7) reviewed for non-pressure skin issues.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess and monitor a pressure wound, failed to timely notify the physician of new ulcer development, and failed to provide physician ordered treatments for 1 of 1 resident (R6) reviewed for skin integrity.

Inspectors wroteBased on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 2 of 3 residents (R1, R4) who were noted to have missing information in their record.

Inspectors wroteBased on interview, and document review the facility failed to ensure there was a communication process between the long-term care (LTC) facility and the hospice provider to ensure the needs of the resident are addressed and met 24 hours per day. In addition, the facility failed to ensure a designated interdisciplinary team member (IDT) was responsible for the coordinating with hospice representative and LTC staff in the hospice care planning process for 2 of 2 residents (R2, R5) reviewed for hospice services.

Inspectors wroteBased on interview and record review, the facility failed to determine whether a resident was safe to self-monitor diabetic medication treatment results (blood glucose levels) for 1 of 1 residents (R13) who had a continuous blood glucose monitoring system (FreeStyle 3 Libre).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff were competent to use a continuous glucose monitoring device (FreeStyle Libre 3) for 1 of 1 resident (R)13 who had a diagnosis of diabetes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietary staff had appropriate training with competencies to carry out the function of monitoring the dish machine temperatures to ensure appropriate sanitation occurred.

Inspectors wroteBased on interview and document review the facility failed to develop and implement 1 of 1 facility assessment to ensure staff were trained and deemed competent for blood glucose monitoring and device usage. In addition, the facility failed to ensure 1 of 1 dietary aides (DA-A) was trained to ensure appropriate sanitation occurred in the dishwashing machine.

Inspectors wroteBased on interview and document review the facility failed to ensure psychotropic medications had identified target behaviors or symptoms, failed to monitor the target behaviors or symptom, and failed to monitor for adverse effects of the medication for 1 of 4 residents (R4) reviewed for psychotropic medication use. Additionally, the facility failed to have non-pharmacological meaningful interventions that were personalized for target behaviors or symptoms.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 12 sampled residents (R24).

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that addressed anticoagulant (prevents and breaks down blood clots) therapy with safety precautions for 1 of 1 (R25) resident reviewed for care plan.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise 1 of 1 resident (R8) care plan following a change of condition.

Inspectors wroteBased on observation, interview and document review, the facility failed to have an integrated care plan to coordinate and delineate what services hospice was to provide and what services the facility was to provide, to ensure oversight and services would be provided for 1 of 1 resident (R11) reviewed for hospice care.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 staff (housekeeping aide (HK)-A) was appropriately given a second tuberculosis test within 1-2 weeks after the first step was completed upon hire. Review of the current, undated Regulations for Tuberculosis Control in Minnesota Health Care Settings, located at https://www.health.state.mn.us/diseases/tb/rules/tbregsmanual.pdf for Tuberculosis Control in Minnesota Health Care Settings, identified baseline TB screening is required for all healthcare workers (HCW). Baseline TB screening consists of three components: 1. Assessing for current symptoms of active TB disease, 2. Assessing TB history, and 3. Testing for the presence of infection with Mycobacterium tuberculosis by administering either a two-step TST or single IGRA.before hire. [...]

Inspectors wroteBased on interview and document review, the facility failed to complete a review of antibiotic therapy between 48-72 hours to ensure appropriateness of the continued use of an antibiotic for 1 of 3 (R21) sampled residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 (R28) were offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC).

Inspectors wroteBased on observation, interview and record review the facility failed to comprehensively assess and provide an adequate plan for supervision and appropriate interventions to protect, respect and promote rights of the resident to meet individual needs, for 1 of 3 residents (R1) reviewed for elopement. Additionally, the facility failed to ensure 1 of 1 (R1) resident care plans were revised and staff were aware of interventions to maintain resident safety.

Inspectors wroteBased on interview and document review the facility failed to immediately report an allegation of abuse to the administrator and State Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of abuse.

Inspectors wroteBased on observation, interview, and document review the facility failed to implement enhanced barrier precautions (EBP) and ensure personal protective equipment (PPE) was used according to EBP indications for high-contact resident care activities for 2 of 2 residents (R5 and R18) with a wound and indwelling catheter. Additionally, the facility failed to monitor, track and trend for signs and symptoms of infections in the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure the acting infection preventionist (IP) (who is the facility's director of nursing (DON)) had completed specialized training in infection prevention and control. This had the potential to affect all 21 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure privacy of resident's medical information for 1 of 1 facility medication cart which involved 10 of 21 residents (R1, R4, R5, R6, R7, R8, R10, R11, R18, and R175). This had the potential to be viewed by any resident and visitor passing by common room across from the nursing station.

Inspectors wroteBased on interview and document review, the facility failed to ensure 4 of 5 sampled residents (R172, R173, R174 and R175) were appropriately vaccinated against pneumonia upon admission.

Inspectors wroteBased on interview and document review, the facility failed to offer the Coronavirus (COVID-19) vaccine to 2 of 5 residents (R172 and R173) reviewed for COVID immunizations upon admission.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate infection control technique during 1 of 1 meal service. This had the potential to affect all 23 residents in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement infection control practices in accordance with Centers for Disease Control (CDC) recommendations to prevent and/or mitigate the risk of the spread of communicable disease Influenza such as utilization of appropriate personal protective equipment (PPE), appropriate hand hygiene, preventing ill staff from working, implement active symptom screening for residents and staff, and providing staff ongoing education during outbreak. The facility's failures resulted in an Influenza A outbreak that effected 9 out out of 23 residents and had the potential to effect the remaining residents, visitors, and staff.

Inspectors wroteBased on interview and document review, the facility failed to ensure the facility determined the required time needed for the infection preventionist based on the facility assessment, resident census and characteristics, and during communicable disease outbreaks. Further failed to ensure the IP was afforded adequate time and resources to effectively execute infection control program activities to prevent and/or mitigate the risk of infectious spread.

Inspectors wroteBased on interview and document review the facility failed to ensure all staff working in the dietary department had training on use of equipment, safe temperatures to ensure food safety and sanitation processes. This had the potential to affect all 23 residents in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents had access to their personal funds upon request for 1 of 1 resident (R5) reviewed. This had the potential to effect 14 residents who utilized a personal funds account.

Inspectors wroteBased on interview and document review the facility failed to provide required timely notifications for 1 of 2 residents ( R4) who experienced falls.

Inspectors wroteBased on interview and document review the facility failed to provide adequate and specialized rehabilitative services of occupational therapy (OT) and physical therapy (PT) therapy according to residents individualized needs based on a comprehensive assessment for 2 of 2 residents (R2 and R10) who had orders for physical therapy (PT) and occupational therapy (OT).

Inspectors wroteBased on observation, interview, and document review the facility failed to complete comprehensively assess and provide adequate of level of supervision to prevent elopement for 1 of 1 residents (R1) who had a history of elopements and fall with fracture.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of crime in accordance with section 1150B of the Act when they were notified of suspected criminal activity by a resident (R2) occurring in the facility.