Valley Grande Manor

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jul 25, 2025

  Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from were verbal and physical abuse by a resident for 6 of 6 residents (Residents #5, #71, #82, #88, #95, #99) reviewed for abuse, in that: 1.The facility failed to ensure Resident #71 was free abuse when Resident #88 hit Resident #71 on the head on 01/24/25. 2. The facility failed to ensure Resident #71 was free from abuse when Resident #88 had a physical altercation with Resident #71 on 04/05/25. 3. The facility failed to ensure Resident #82, and Resident #99 were free from abuse when Resident #88 had a physical altercation with Resident #82 and Resident #99 on 06/04/25. […]

• Immediate jeopardy, patternF580Dec 21, 2023

  Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental or psychological status for 1 of 3 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify the resident's physician when Resident #1 was noticed with discoloration to her outer lower leg on 11/29/2023. On 12/19/2023 at 3:40 p.m., an Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, patternF684Dec 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 was accurately assessed after being discovered with abnormal discoloration to her lower outer left leg on 11/29/2023. Between 11/29/2023 to 12/08/2023, Resident #1 was observed crying and with facial grimacing. Resident #1 was diagnosed with a left ankle fracture. On 12/19/2023 at 3:40 p.m., an Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, isolatedF689Apr 30, 2024

  Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1 ) reviewed for accidents and supervision, in that: 1. The facility failed to ensure Resident #1 received supervision to prevent Resident #1 from eloping from the facility undetected on 04/29/2023. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2023 and ended on 05/01/2023. The facility corrected the non-compliance before the investigation began. This failure could place the residents with exit seeking behaviors and repeated falls at risk for injury or death. […]

• Actual harm, isolatedF600Jun 5, 2025

  Based on record review and interview, the facility failed to ensure residents were free from neglect for 1 (Resident #1) of 5 residents reviewed for abuse/neglect, in that: The facility failed to ensure Resident #1, who required 2 or more staff per her care plan was provided with the appropriate number of staff while in the shower chair. As a result, the resident had a fall when she was left unattended and sustained a broken toe. This failure could place residents at risk of emotional distress, fear, decreased quality of life, and further neglect. Findings included: Record review of Resident #1's admission record revealed she was an [AGE] year-old female with an admission date of 01/13/21. […]