Inspection Reports for Protection Valley Manor

An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS to investigate an immediate jeopardy incident involving Resident 1 eloping from the facility through an unsecured front door.

The facility failed to ensure operational door locks, alarms, and adequate supervision for Resident 1, who was at high risk for elopement, resulting in the resident leaving the facility unsupervised. Corrective actions were completed prior to the survey, and the deficiency was cited as past noncompliance at a scope and severity of 'J'.

An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS on 07/01/25 to assess compliance with 42 CFR 483 subpart B.

The facility was found not to be in substantial compliance with regulations. Corrective actions included implementation of a WanderGuard system with visual checks, a new override code procedure, staff education on elopement prevention, a Quality Assurance meeting, and policy updates. All corrections were completed prior to the onsite survey, and the deficient practice was cited as past noncompliance at a scope and severity of 'J'.

An offsite revisit survey was conducted on 04/14/25 for all previous deficiencies cited on 03/05/25.

All deficiencies have been corrected as of the compliance date of 04/04/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection at Protection Valley Manor.

The plan addresses deficiencies related to food storage practices and hand hygiene/Enhanced Barrier Precautions (EBP). Corrective actions include policy revisions, staff training, competency checks, signage updates, and ongoing monitoring for compliance.

The inspection was a Health Recertification Survey to assess compliance with food safety and infection control regulations.

The facility failed to store, prepare, and serve food in a sanitary manner, risking food-borne illness. Additionally, the facility did not properly implement infection prevention and control protocols, including failure to identify residents on Enhanced Barrier Precautions (EBP) and inadequate hand hygiene by staff.

An offsite revisit survey was conducted on 05/06/2023 for all previous deficiencies cited on 03/16/2023 to verify correction of cited deficiencies.

All deficiencies have been corrected as of the compliance date of 04/14/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 3-16-2023 for Protection Valley Manor.

The plan addresses deficiencies related to care plan revisions following resident falls and dietary staff practices concerning food storage and sanitation to prevent food borne illnesses.

The inspection was a Health Resurvey conducted to review compliance with care plan timing and revision requirements and food safety standards.

The facility failed to review and revise care plans for three residents related to fall prevention interventions after multiple falls. Additionally, the facility failed to maintain sanitary food preparation, storage, and serving conditions, risking foodborne illness.

An offsite revisit survey was conducted on 10/25/21 for all previous deficiencies cited on 08/30/21.

All deficiencies have been corrected as of the compliance date of 10/08/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 08-30-2021.

The plan addresses multiple deficiencies including bed hold notification, timely submission of death in facility MDS, care plan revisions, accurate skin assessments, and safe storage of chemicals. Corrective actions and monitoring responsibilities are outlined for each deficiency.

The inspection was a Health Resurvey to evaluate compliance with previously cited deficiencies and regulatory requirements.

The facility was found deficient in multiple areas including failure to provide bed-hold policy upon hospital transfer, untimely completion of required resident assessments, failure to update care plans timely after falls and changes in resident condition, failure to provide care and treatment according to professional standards including wound care and skin assessments, and failure to maintain a safe environment by securing hazardous chemicals.

A COVID-19 Focused Emergency Preparedness Survey and a Targeted Infection Control Survey/COVID-19 Focused Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness.

The facility was found to be in compliance with 42 CFR §483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.

A revisit survey was conducted on 07/23/2020 for all previous deficiencies cited on 06/16/2020.

All deficiencies have been corrected as of the compliance date of 06/17/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies identified related to COVID-19 exposure prevention practices at the facility.

The facility had deficient practices related to COVID-19 exposure prevention, including inadequate screening and masking policies. The plan outlines corrective actions such as staff wearing masks in resident areas, screening all entrants, securing facility entryways, and staff education on infection control.

A Targeted Infection Control/COVID-19 Survey was conducted due to concerns about the facility's failure to promptly review staff and visitor screenings for COVID-19 symptoms and failure of staff to wear protective masks, constituting immediate jeopardy.

The facility failed to promptly review COVID-19 screenings for staff and visitors before entry and failed to ensure staff wore protective face masks while in the facility, placing all 42 residents in immediate jeopardy. The facility presented an acceptable plan of removal which was validated by the survey team the following day.

An offsite revisit survey was conducted on 01/31/2020 for all previous deficiencies cited on 12/05/19.

All deficiencies have been corrected as of the compliance date of 01/15/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 2019-12-05. It outlines corrective actions the facility will take to address identified deficiencies.

The Plan of Correction addresses multiple deficiencies including mail delivery, monitoring of resident behaviors, updating activity calendars, securing service hallway doors, staff training, posting staffing hours, behavior monitoring related to antipsychotic medications, proper insulin dating, and cleaning of blood glucose monitors. The facility commits to monitoring and sustaining compliance with these corrective actions.

The inspection was a health resurvey to assess compliance with regulatory requirements and to investigate specific complaints and concerns related to resident rights, care planning, activities, safety, staffing, medication management, and infection control.

The facility was found deficient in multiple areas including failure to provide timely mail delivery, incomplete care plan revisions for targeted behaviors, inadequate activity programming on weekends, unsafe environment hazards, incomplete nurse aide in-service training, improper posting of nurse staffing information, failure to monitor unnecessary psychotropic medications, improper medication labeling and storage, and lapses in infection prevention and control practices.

An offsite revisit survey was conducted on 01/24/2019 for all previous deficiencies cited on 11/06/2018.

All deficiencies have been corrected as of the compliance date of 12/01/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted in response to deficiencies identified in the Protection Valley Manor inspection conducted on November 6, 2018.

The plan addresses deficiencies related to fall investigations, root cause analysis, care plan updates, and registered nurse supervision. The facility commits to weekly fall reviews by an interdisciplinary team, education for nursing staff, and ensuring eight hours of registered nurse supervision daily.

A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-12-01.

The inspection was conducted as a health resurvey to assess compliance with comprehensive assessments, timing, accident hazards, supervision, and staffing requirements.

The facility failed to ensure a resident remained in a safe environment by not adequately planning interventions or revising care plans to prevent falls. Additionally, the facility failed to determine causal factors for falls and did not provide 8 hours of registered nurse coverage on 15 days during the review period.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected and to confirm the date such corrective actions were accomplished.

All previously cited deficiencies listed with their regulation numbers and identification prefixes were marked as corrected and completed as of 05/09/2017.

A Health recertification survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The facility was found not in substantial compliance with participation requirements, constituting immediate jeopardy to resident health or safety from January 19, 2017 through April 8, 2017. Deficiencies cited included substandard quality of care related to F323"J" CFR 01-483.25(h).

The inspection was conducted as a Health Resurvey, Extended Health Survey and Complaint Investigation.

The facility had multiple deficiencies including failure to hold a sufficient surety bond for resident funds, incomplete comprehensive assessments and care area assessments (CAAs) for multiple residents, failure to revise care plans to reflect moderate risk for elopement, failure to prevent pressure ulcers, failure to provide restorative services for range of motion, inadequate supervision for residents at risk of elopement, failure to assess bed rails for entrapment hazards, failure to complete root cause analysis and implement fall interventions, failure to ensure food safety in nutrition refrigerators, failure to have signed physician admission orders, failure to ensure timely physician visits, failure to hold insulin per physician orders, failure to review medication administration during pharmacy reviews, failure to maintain sanitary environment and hand hygiene by housekeeping, failure to verify nurse aide registry status prior to employment, failure to provide nurse aide competency checks, and failure to have a contract for diagnostic services.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

All previously cited deficiencies related to various regulatory requirements were corrected as of 10/21/2016, with no uncorrected deficiencies noted at the time of this revisit.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, addressing issues such as investigation procedures, resident care plans, supervision to prevent burns, and call light system functionality.

The facility failed to conduct thorough investigations, revise care plans for safety concerns related to hot liquids, provide adequate supervision to prevent accidental burns, and maintain a functioning call light system accessible to residents, resulting in multiple deficiencies.

An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be F323, "K", CFR 483.25(h), which was immediate jeopardy from September 18, 2016 to September 28, 2016. The facility was found to have substandard quality of care and immediate jeopardy was abated.

The inspection was conducted as a complaint investigation and partial extended survey to evaluate the facility's compliance with nursing facility support system requirements, specifically regarding the call light system functionality and emergency call buttons.

The facility failed to develop and implement a preventative maintenance program to test the call light system weekly, resulting in multiple call lights and emergency call buttons not functioning or registering alerts at the nurses' station or on pagers. This deficient practice had the potential to affect all 44 residents in the facility.

The visit was triggered by a complaint investigation and partial extended survey #105847. The complaint involved non-functioning call lights and emergency call buttons, which were confirmed by observations, interviews, and record reviews.

This document is a Plan of Correction submitted by Protection Valley Manor addressing multiple deficiencies identified in a prior inspection, outlining corrective actions to comply with Federal Medicare and Medicaid requirements.

The plan addresses deficiencies related to resident rights, care planning participation, accident prevention, medication management, infection control, and quality assurance. The facility commits to policy revisions, staff education, monitoring, and documentation to prevent recurrence of deficiencies.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.

All previously reported deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The inspection was conducted as a health resurvey and complaint investigation #91431 to assess compliance with resident rights, self-determination, care planning, accident prevention, drug regimen, infection control, and quality assurance requirements.

The facility failed to periodically inform residents of their rights, failed to assess and follow resident preferences, did not review and revise care plans after falls, failed to thoroughly investigate falls and implement interventions, failed to ensure residents were free from unnecessary drugs including monitoring for black box warnings and behaviors, failed to label and date insulin products, failed to ensure proper hand hygiene during feeding, failed to track infection organisms for trending, and failed to ensure physician attendance at quality assurance meetings.

The visit was triggered by complaint investigation #91431 related to resident rights, care planning, accident prevention, drug regimen, infection control, and quality assurance.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.

This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.

The report confirms that the previously cited deficiency with ID Prefix S1174 and Regulation 26-40-303 (2)(a)(i)(ii)(iii) was corrected as of 07/09/2014.

This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected by the facility.

All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.

The inspection was a Health Resurvey to assess compliance with regulatory requirements including housekeeping, care planning, medication management, immunizations, and food safety.

The facility failed to maintain a sanitary environment in resident bathrooms, develop comprehensive care plans for dental and fall-related care, ensure safe medication use with proper behavior monitoring and black box warnings, maintain immunization documentation, and enforce sanitary food preparation practices including hair restraints and food temperature monitoring.

This document is a Plan of Correction submitted by Protection Valley Manor to address deficiencies identified in a prior CMS-2567 statement of deficiencies report.

The plan outlines corrective actions to address multiple deficiencies including abuse prevention, reasonable accommodation of resident needs, activity programming, comprehensive assessments, care plans, wound care, accident prevention, and quality assurance processes.

This is a post-certification revisit to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.

All previously reported deficiencies identified by regulation numbers 483.13(c), 483.15(e)(1), 483.15(f)(1), 483.20(b)(1), 483.20(d), 483.20(k)(1), 483.25, 483.25(c), 483.25(h), and 483.75(o)(1) were corrected as of the revisit date.

The inspection was conducted as a health survey and complaint survey into complaint #62578, focusing on allegations of abuse, neglect, and mistreatment, as well as other regulatory compliance issues.

The facility was found deficient in multiple areas including failure to develop and implement abuse/neglect policies, failure to accommodate resident needs such as call light access, inadequate activity programs especially for cognitively impaired residents, incomplete comprehensive assessments and care area assessments, failure to develop comprehensive care plans addressing activities and pain, inadequate pain management, failure to properly assess and measure pressure ulcers, and inadequate supervision and accident prevention measures. The facility's Quality Assurance program failed to adequately address these deficiencies.

The inspection was triggered by complaint #62578 regarding allegations of abuse and neglect. The complaint was substantiated as the facility failed to develop and implement appropriate policies and procedures to handle abuse allegations and protect residents during investigations.

This document is a Plan of Correction submitted by Protection Valley Manor in response to deficiencies identified in a prior inspection.

The plan outlines corrective actions taken or to be taken for multiple deficiencies including financial surety bonds, care area assessments, resident care plans, pressure ulcer prevention, restorative services, bed rail safety, elopement risk, fall investigations, food safety, physician orders, staff competency, and diagnostic service contracts.

This document is a Plan of Correction submitted by Protection Valley Manor addressing multiple deficiencies identified in a prior inspection related to housekeeping, care planning, resident participation, fall prevention, medication management, immunizations, food safety, and facility safety.

The plan outlines corrective actions including policy development, staff education, resident involvement, audits, and follow-up measures to ensure compliance with federal Medicare and Medicaid requirements and to prevent recurrence of the cited deficiencies.