Inspection Reports for
Protection Valley Manor

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Corrections related to elopement prevention, WanderGuard use, override code procedures, staff education, and policy updates were completed prior to the onsite survey.

The facility failed to ensure operational door locks, alarms, and adequate supervision for a cognitively impaired resident at high risk for elopement, resulting in the resident leaving the facility unsupervised through an unlocked door. Corrective actions were completed prior to the survey and verified on-site.

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

The facility failed to store, prepare, and serve food in a sanitary manner and did not follow infection prevention protocols, including failure to identify residents on Enhanced Barrier Precautions and improper hand hygiene by staff, placing residents at risk for food-borne illness and infectious diseases.

The facility identified deficiencies related to care plan revisions following resident falls and improper food storage and sanitation practices in the dietary department. Corrective actions and staff education plans were implemented to address these issues and ensure ongoing compliance.

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, creating potential for foodborne illness.

The plan outlines corrective actions for deficiencies related to bed hold notifications, death reporting, care plan revisions, skin assessments, and chemical storage safety.

The facility failed to provide required bed-hold policy notices upon resident transfer to hospital, timely completion and transmission of Minimum Data Set (MDS) assessments, timely care plan updates for residents after falls and changes in condition, and adequate treatment and care including dressing changes and skin assessments. Additionally, the facility failed to secure hazardous chemicals from resident access.

The facility had deficient practices related to COVID-19 exposure prevention, including inadequate screening and masking policies. The plan outlines corrective actions to secure entry, enforce mask-wearing, and educate staff to prevent recurrence.

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 of immediate jeopardy which was validated by the survey team.

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 medication use, improper medication labeling and storage, and lapses in infection prevention and control practices.

The survey found the most serious deficiencies 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 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 ensure 8 hours of registered nurse coverage on multiple days.

The facility had multiple deficiencies including failure to hold a sufficient surety bond for resident funds, incomplete comprehensive assessments and care area assessments, failure to revise care plans for elopement risk, 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 interventions after falls, failure to monitor food storage temperatures and remove expired food, failure to obtain signed physician admission orders, failure to ensure timely physician visits, failure to obtain physician orders for holding insulin, failure to review medication administration for irregularities, failure to maintain infection control practices, failure to verify nurse aide registry status, failure to provide nurse aide competency checks, and failure to have a contract for diagnostic services.

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. Enforcement remedies including denial of payment for new admissions, civil money penalty, and potential termination of provider agreement were imposed.

The survey found the most serious deficiencies at the facility to be at the 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

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

The survey found immediate jeopardy related to deficiency F323, "K", CFR 483.25(h), which was present from September 18, 2016 to September 28, 2016. Enforcement remedies including a civil money penalty and potential termination of provider agreement were imposed.

The visit was triggered by a complaint investigation and partial extended survey #105847. The complaint involved failure of the call light system and emergency call buttons to function properly, which was substantiated by observations and interviews.

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 being accessible. This deficient practice had the potential to affect all residents in the facility.

The report shows that all previously identified deficiencies were corrected by the revisit date of 11/01/2015, with corrections documented for multiple regulatory requirements.

The plan outlines corrective actions for multiple deficiencies including resident rights notification, choice in activities and care planning, fall prevention, medication management, infection control, and quality assurance processes. Each corrective action includes responsible staff and timelines for implementation by November 1, 2015.

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 which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection included a complaint investigation #91431.

The facility was found deficient in multiple areas including failure to periodically inform residents of their rights, failure to assess and follow resident preferences, failure to review and revise care plans after falls, failure to thoroughly investigate falls and implement interventions, failure to ensure drug regimens were free from unnecessary drugs including monitoring of black box warnings and behaviors, failure to label and date food items and medications properly, failure to maintain infection control practices including hand hygiene and infection tracking, and failure to ensure physician attendance at quality assurance meetings.

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

The report documents that the previously identified deficiency under regulation 26-40-303 (2)(a)(i)(ii)(iii) was corrected as of the revisit date.

The facility had multiple deficiencies including failure to maintain sanitary conditions in resident bathrooms, failure to develop and revise comprehensive care plans, inadequate investigation and prevention of resident falls, failure to monitor and document behaviors related to psychoactive medications and black box warnings, incomplete immunization documentation, and food safety violations including improper hair restraints and failure to take food temperatures.

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

The plan details multiple corrective actions including new policies, staff education, resident assessments, activity programming, and quality assurance measures to address issues such as abuse prevention, accommodation of resident needs, comprehensive assessments, care plans, pressure sore prevention, accident prevention, and psychosocial needs.

Complaint #62578 triggered the survey focusing on abuse, neglect, mistreatment, and other care deficiencies.

The facility failed to develop and implement adequate policies and procedures regarding abuse and neglect, failed to accommodate resident needs such as call light access, lacked adequate activities programming especially for cognitively impaired residents, failed to complete comprehensive assessments and care plans timely and accurately, failed to manage resident pain effectively, failed to properly assess and treat pressure ulcers, and failed to provide adequate supervision and accident prevention measures.

The Plan of Correction addresses multiple deficiencies including resident trust account bonding, care area assessments, care plan updates, pressure ulcer prevention, restorative services, bed rail safety, elopement risk, fall investigations, food safety, physician orders, medication management, room cleaning, CNA registry verification, competency testing, and diagnostic service contracts.

The plan outlines corrective actions for fall investigations, root cause analysis, care plan updates, and ensuring adequate registered nurse supervision for eight hours daily.

The plan outlines corrective actions including policy development, staff education, resident involvement, and administrative oversight to ensure compliance with federal Medicare and Medicaid requirements and to prevent recurrence of identified deficiencies.

The Plan of Correction outlines corrective actions for multiple deficiencies including mail delivery, behavior monitoring, activity scheduling, door security, staff training, staffing hours posting, medication monitoring, insulin handling, and blood glucose monitor cleaning.