Valley Manor Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Valley Manor Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 28, 2024

  Based on clinical record review, policy review, review of facility documentation, observation, and staff interviews, it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) by one of 16 sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include: Review of the facility policy entitled, Elopement, last reviewed on September 28, 2023, revealed that staff was to monitor residents' whereabouts who were at risk for unsafe wandering and elopement. […]

• No harm, potential for more than minimal, widespreadF812Feb 14, 2024

  Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen and on two of three nursing units. (Central and South units) Findings include: A review of the facility policy entitled, Food Policy, last reviewed [DATE], revealed that the facility maintained personal food in accordance with safe food guidelines. Food was to be stored in the refrigerator or freezer in airtight containers, and labeled with the resident's name, room number, and the date it was placed in the refrigerator. Items were to be discarded after 72 hours. […]

• No harm, potential for more than minimal, widespreadF803Mar 17, 2023

  Based on resident interview, observation, facility documentation, and staff interview, it was determined that the facility failed to follow the pre-approved menus. Findings include: During the Resident Council interview conducted on March 16, 2023, at 1:00 p.m., five of seven residents stated that menu items are frequently substituted, and they did not know what foods they would receive for their meals. Review of the facility menus revealed the lunch meal on March 14, 2023, was to include turkey scalopini, orzo with vegetables, sauteed broccoli florets, and banana pudding. The lunch meal on March 15, 2023, was to include country fried steak, beef brown gravy, whipped potatoes, green and gold beans, and chilled peaches. […]

• No harm, potential for more than minimal, widespreadF838Mar 17, 2023

  Based on staff interview, it was determined that the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to competently care for residents in emergencies and day-to-day operations. Findings include: During an interview on March 17, 2023, at 3:20 p.m., the Nursing Home Administrator reported that the facility did not conduct and document a facility-wide assessment.

• No harm, potential for more than minimal, widespreadF880Mar 17, 2023

  Based on policy review, facility documentation review, and staff interview, it was determined that the facility failed to perform infection surveillance in accordance with facility policy. Findings include: Review of the facility policy entitled, Infection Outcome Surveillance, last reviewed January 26, 2023, revealed that the facility would use a systematic method of collecting, consolidating, and analyzing data concerning the distribution and determining factor of a given disease or event. Review of the facility infection control program on March 16, 2023, at 12:57 p.m., revealed there was no documented evidence of infection surveillance since March 2022. […]