Madison Valley Manor

In the surveyor’s words

From the most serious findings on record at Madison Valley Manor, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 5, 2021

  Based on interview and record review, the facility failed to ensure residents were free from physical and verbal abuse, and neglect of care by staff, for 2 (#s 120 and 121) of 8 sampled residents. Findings include: A review of the facility's concern form, dated 9/1/20, showed staff member D had reported observing the following statements and actions by staff member E, which included physical and verbal abuse, and neglect of a resident(s) care needs: - . told a resident to 'sit the [f**k] down' while pulling them down to the toilet. - . forced open the legs of a resident that was being resistant to peri-care. - . 'You've never done this [sh*t] before.' - . […]

• No harm, potential for more than minimal, widespreadF812May 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure foods were dated and labeled when opened, disposed of when expired, and failed to maintain a clean kitchen environment. This failure increased the risk of unsanitary conditions and foodborne illnesses, for individuals consuming food stored in the facility kitchen and resident refrigerator, and from food prepared in the facility kitchen. Findings include: 1. Unlabeled/Undated/Expired Foods During an observation on 5/5/25 at 1:03 p.m., the following items were seen in the dry storage area: - one bag of vermicelli pasta, open and undated, - one box of vanilla maple cereal, open and undated, - one box of Jello mix, expiration date of 2022, - one box of Jello mix, expiration date of 2023, - one bottle of Karo… […]

• No harm, potential for more than minimal, widespreadF908May 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of the freezers was adequately maintained, in safe operating condition, in the kitchen. This failure increased the risk of foodborne illnesses for individuals consuming food prepared from the facility kitchen. Findings include: During an observation on 5/5/25 at 1:33 p.m., the bottom level shelves of the kitchen entry way freezer had two cardboard signs reading, Do Not Use. Food items were stored on all shelves of the freezer except the bottom level. During an interview on 5/7/25 at 2:56 p.m., staff member F stated there were plans to renovate and remodel the kitchen. Staff member F stated the freezer needed to be replaced. […]

• No harm, potential for more than minimal, patternF604May 8, 2025

  Based on observation, interview, and record review, the facility failed to perform and document a complete resident assessment prior to the use of bed rails as a restraint for 1 (#7); failed to complete and document a resident assessment prior to the use of a scoop mattress for 1 (#17); and failed to perform and document ongoing monitoring of the appropriate use of assistive devices which could be considered a restraint for 2 (#14 and #17) of 15 sampled residents. These failures increase the risk of injury for the residents. Findings include: 1. During an observation and interview on 5/5/25 at 2:04 p.m., resident #7 was in his room seated in his wheelchair. The resident's bed was noted to have upper half bed rails placed and pulled up on both sides of the bed. […]

• No harm, potential for more than minimal, patternF945Sep 10, 2024

  Based on observation, interview, and record review, the facility failed to have a system in place to ensure temporary agency staff were trained on the facility's infection prevention and control program standards, policies, and procedures. This deficient practice had the potential to affect residents who worked with or were affected by the untrained staff. Findings include: During an interview on 9/9/24 at 10:19 a.m., staff member C stated she had been employed at the facility as a traveling CNA for approximately six months. […]