Valley Manor Care Center

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

K-511 Utilities – Gas and ElectricThrough observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by:1) Gas valves on the dryer(s) not rated for more than 2000 feet elevation need high-elevation gas valvesNFPA 54 11.1.2 High Altitude.Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of applia.. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register, Section 42 CFR 483.70(a).Life safety features that meet the requirements for new construction at the time of licensure or certification shall be maintained and not diminished.The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility' s general characteristics.The facility, which is licensed for 101 beds and had a.. Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Not ProvidedNFPA 996.3.4.1.1Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or s.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by: 1) Fire Alarm Annual: Not provided, last shown is 2.17.23 had deficiencies 2) Fire Alarm Semi-Annual: Not ProvidedBased on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety .. Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by:1) Need to clear the egress path from the dining room to the public way2) The egress pathway to the public way from memory care is obstructed by the west gateNFPA 101 7.1.10.1* General.Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire .. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) Need to add fire caulking to all nursery call wiring penetrations through fire barriers; also need to fix ceiling membrane penetrationsNFPA 10119.3.6.2.2* Corridor walls shall have a minimum 1/2-hour fire resistance rating.19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke... Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) The salon deemed hazardous area needs door closure NFPA 101 21.3.2.1 Doors. Doors to hazardous areas shall be self-closingor automatic closing in accordance with 21.2.2.4.NFPA 101 21.3.2 Protection from HazardsThis deficiency could affect occupants, who might include residents, staff, and vi.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99. This was evidenced by:1) Need proper signage for oxygen use NFPA 10111.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.11.3.4.2 The sign shall include the following wording as a minimum:CAUTION:OXIDIZING GAS(ES) S.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:1) Chapel double fire door not latching2) fire door labels are painted over3) sunshine double fire door not latching4) four-way double door not latching5) rehab hall door closure sticks and prevents a 90 degree open within 15 lbs of force6) rehab gym fire doors not latching7) garden fire ..

A recertification survey was conducted from 5/20/24 to 5/23/24. Ten deficiencies were cited. An Emergency Preparedness survey was conducted from 5/20/24 to 5/23/24. No deficiencies were cited. Based on interviews and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for two (#30 and #21) of five residents reviewed for medications out of 38 sample residents.Specifically, the facility failed to ensure as needed (PRN) psychotropic medications were discontinued after 14 days for Resident #.. Based on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature.Specifically, the facility failed to ensure the residents' food was palatable in taste, texture, appearance .. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on two of two units.Specifically, the facility failed to wipe down a shared mechanical lift and slings betwee.. Based on observations, interviews and record review, the facility failed to ensure residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being for two (#6 and #66) of six residents reviewed for dementia care out of 38 sample residents.Specifically, the facility failed to:-Ef.. Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#50) of three residents out of 38 sample residentsSpecifically, the facility failed to ensure staff used a gait belt appropriately for assistance and not to restrain a resident from getting out of her wheelchair.Finding.. Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of three dining rooms and one of one kitchenette.Specifically, the facility failed to:-Ensure hand hygiene was offered and provided to residents during meal times; -Ensure staff plating ready-to-eat food used h.. Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for two (#66 and #6) of five residents reviewed for abuse out of 38 sample residents.Specifically, the facility failed to: -Prevent Resident #6 from physically abusing Resident #66;-Update Resident #66 and Resident #6' s care plans with effective in.. Based on record review and interviews, the facility failed to ensure the resident' s legal representative was provided an opportunity to exercise a right on behalf of the resident for one (#30) of five residents reviewed for resident rights out of 38 sample residents.Specifically, the facility failed to:-Ensure Resident #30' s Medical Orders for Scope of Treatmen.. Based on record review and interviews, the facility failed to ensure two (#17 and #39) of five residents out of 38 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being.Resident #17 was admitted to the facility on 2/11/21 with diagnoses of chro.. Based on resident and staff interviews and record review, the facility failed to act promptly upon the grievances concerning issues of resident care and life in the facility that were important to the residents.Specifically, the facility failed to effectively address, resolve and maintain a systematic approach to ongoing resident concerns of staff treat..

A licensure survey was completed on 5/20/24 to 5/23/24. One deficiency was cited. Based on record review and interviews, the facility failed to ensure two (#17 and #39) of five residents out of 38 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being.Resident #17 was admitted to the facility on 2/11/21 with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure and severe protein-calorie malnutrition. On 10/4/23, the resident weighed 137 pounds (lbs). On 10/25/23 the resident sustained a 5.8% (percent) (7.88 lbs) weight loss in 21 days, which was considered severe. After the resident sustained the weight loss the facility failed to implement additional nutritional interventions to address the resident' s weight loss. The resident sustained an additional 8.5% (11.8 lbs) weight loss from 10/25/23 to 11/22/23, which was considered significant. The facility failed to implement additional nutritional interventions to address the resident' s continued severe weight loss. On 11/8/23 a physician' s order was entered into the resident' s electronic medical record (EMR) which indicated to weigh the resident weekly on Wednesdays. The facility failed to consistently monitor the resident' s weight. On 2/14/24, the resident weighed 111 lbs. The resident sustained 19% (26 lbs) weight loss from 10/4/23 to 2/14/24, which was considered severe. The only nutrition intervention that was implemented was a nutritional supplement in September 2023, prior to the resident sustaining severe weight loss. The facility failed to provide the supplement as ordered and consistently document the amount the resident consumed when the oral nutritional supplement was offered. Additionally, the facility failed to monitor and track Resident #39' s weight loss and implement person-centered nutritional interventions to address the resident' s weight loss. Findings include:I. Facility policy and procedureThe Comprehensive Medical Nutrition Therapy Assessment policy, revised 2021, was provided by the nursing home administrator (NHA) on 5/23/2..