Valley View Manor Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 20, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Nov 19, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 24, 2022

  Based on interview, observation, and document review, the facility failed to provide adequate supervision and safeguards to prevent elopement for by not following manufacturer's guidelines for the use of WanderGuard bracelets for 2 of 2 residents (R1, R2) who were determined to be at risk for elopement and required the use of a WanderGuard for safety resulting in an Immediate Jeopardy. In addition, the facility failed to implement interventions to prevent future elopements and failed to update care plan interventions related to elopement/wandering behaviors for 1 of 2 residents (R1) following an elopement. The immediate jeopardy began on [DATE], when R1, who was identified as a high elopement risk, was found on the street off the premises and was identified on [DATE]. […]

• Actual harm, isolatedF600Aug 31, 2023

  Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R27) was free from psychosocial abuse by (activity aid (AA)-A). Findings include: R27's 6/22/23, admission Minimum Data Set (MDS) identified R27's cognition was intact, he required limited assistance with bed mobility and extensive assistance with transfers and toileting. R27 had diagnosis of depression, post-traumatic stress disorder (PTSD), developmental disorder of scholastic skills, malnutrition, heart failure, diabetes, and epilepsy. […]

• Actual harm, isolatedF689Sep 28, 2022

  Based on observation, interview, and document review the facility failed to comprehensively assess and care plan safe transfers for the appropriate brand of sit-to-stand mechanical lift and accessories to ensure safe transfers for 1 of 4 residents (R1) reviewed for mechanical lift transfers. This resulted in harm when R1 re-fractued his left humerous (upper arm) during a transfer using a standing mechanical lift. Findings include: During an interview on 9/27/22, at 8:35 a.m. the Administrator indicated the facility was divided into two sections which were identified as Country Side and City Side and were in the process of moving residents from the Country Side of the building to the City Side of the building due to low census and staffing reasons. […]