Inspection Reports for
Valley Manor and Rehabilitation Center
1410 HOSPITAL DR, EXCELSIOR SPRINGS, MO, 64024-1168
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
142% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
56% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 5
Date: Dec 18, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, hygiene, nutrition, food safety, and infection control at Valley Manor and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including incomplete and inaccurate resident care plans, failure to provide timely showers to dependent residents, failure to accommodate resident dietary preferences especially related to religious restrictions, poor food safety and sanitation practices in the kitchen, and inadequate infection prevention and control practices including improper use of personal protective equipment (PPE).
Deficiencies (5)
Failure to ensure resident care plans were created accurately and comprehensively for sampled residents, including failure to address wheelchair seatbelt use and specific care needs.
Failure to provide timely showers for dependent residents unable to carry out activities of daily living, resulting in inadequate personal hygiene.
Failure to honor a resident's religious dietary preferences by serving pork and failing to provide suitable substitutes.
Failure to maintain food service safety standards including improper handwashing, lack of hairnets, poor kitchen cleanliness, inadequate food storage and labeling, expired food items, and improper food presentation.
Failure to implement an effective infection prevention and control program, including failure to use PPE properly and lack of infection surveillance.
Report Facts
Facility census: 67
Resident showers documented: 10
Pork meals served: 29
Expired food items: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Named in infection control deficiency for failure to change gloves and wash hands appropriately |
| CNA A | Certified Nurse Aide | Named in infection control deficiency for failure to use gowns and change gloves properly |
| RN A | Registered Nurse | Interviewed regarding care plan compliance and shower frequency |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan compliance and shower frequency |
| Director of Nursing | DON | Interviewed regarding care plan compliance, shower frequency, and infection control expectations |
| Administrator | Interviewed regarding care plan compliance, shower scheduling, dietary preferences, kitchen oversight, and infection control | |
| Dietary Manager | DM | Interviewed regarding dietary preferences, kitchen sanitation, and food safety |
| Dietary Aide B | Dietary Aide | Interviewed regarding dishwasher sanitation practices |
| Dietary Aide C | Dietary Aide | Observed and interviewed regarding glove use and kitchen sanitation |
Inspection Report
Routine
Census: 63
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medication administration policies, specifically regarding pain management for residents.
Findings
The facility failed to administer prescribed pain medication (pregabalin) to one resident as ordered, resulting in unnecessary pain. Interviews and record reviews confirmed multiple missed doses during April 2025.
Deficiencies (1)
Failure to administer medications for pain management in accordance with the resident's physician orders, causing unnecessary pain for one resident.
Report Facts
Residents affected: 1
Facility census: 63
Missed medication doses: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding medication administration expectations | |
| ADON | Interviewed regarding unexplained gap in medication administration |
Inspection Report
Routine
Census: 68
Deficiencies: 11
Date: Jul 10, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care, safety, infection control, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights, inadequate care planning, delayed and inadequate response to call lights, poor hygiene and grooming care, failure to maintain a safe and clean environment, improper medication administration, inadequate infection control practices, failure to ensure proper nutrition and hydration, and deficiencies in food service safety and sanitation.
Deficiencies (11)
Failure to respect resident rights including timely response to call lights and preserving dignity.
Failure to develop and implement individualized, comprehensive care plans addressing ADLs, grooming, oral care, skin integrity, and psychosocial needs.
Failure to administer medications correctly including eye drops, nasal sprays, and Tylenol dosing errors.
Failure to provide adequate personal hygiene care including perineal care and showering as scheduled.
Failure to maintain a safe, clean, and homelike environment including unclean resident rooms, odors, damaged walls, and poor housekeeping.
Failure to ensure residents knew how to file grievances and failure to follow grievance procedures.
Failure to ensure adequate nutrition and hydration including failure to pass fluids regularly and serve palatable, appropriately prepared meals at proper temperatures.
Failure to ensure food service safety including improper food storage, expired foods, unclean kitchen and equipment, and inadequate cleaning and sanitizing of kitchen surfaces and equipment.
Failure to ensure safe resident transfers including improper use of mechanical lifts and failure to lock wheelchairs during transfers.
Failure to implement infection prevention and control program including failure to place residents on enhanced barrier precautions and improper catheter care.
Failure to implement an antibiotic stewardship program with monitoring and tracking of antibiotic use.
Report Facts
Facility census: 68
Shower frequency: 1
Expired medications: 3
Food temperature: 118.5
Food temperature: 117.6
Dishwasher sanitizer reading: 100
Food storage: 6
Food temperature: 183.5
Food temperature: 130.4
Food temperature: 134.4
Food temperature: 120.3
Food temperature: 130
Food temperature: 118.5
Food temperature: 131.9
Food temperature: 127
Food temperature: 145
Food temperature: 135
Food temperature: 41
Food temperature: 160
Food temperature: 165
Food temperature: 120
Food temperature: 183.5
Food temperature: 187.1
Food temperature: 179.4
Food temperature: 182.3
Food temperature: 167.1
Food temperature: 180.6
Food temperature: 170.9
Food temperature: 148.8
Food temperature: 152.6
Food temperature: 155.1
Food temperature: 130
Food temperature: 120.3
Food temperature: 131.9
Food temperature: 117.6
Food temperature: 130.4
Food temperature: 134.4
Food temperature: 120.3
Food temperature: 130
Food temperature: 118.5
Food temperature: 131.9
Food temperature: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in medication administration deficiencies including eye drops and nasal spray administration |
| CNA D | Certified Nurse Aide | Named in personal care and infection control deficiencies |
| CNA B | Certified Nurse Aide | Named in shower and shaving care deficiencies |
| Dietary Manager | Named in food service and kitchen sanitation deficiencies | |
| Dietary Aide B | Named in food preparation and sanitation deficiencies | |
| Administrator | Named in multiple interviews regarding facility expectations and deficiencies | |
| Director of Nursing | Named in multiple interviews regarding care planning, infection control, and medication administration | |
| NA D | Nurse Aide | Named in personal care and infection control deficiencies |
| CNA A | Certified Nurse Aide | Named in personal care deficiencies |
| CNA C | Certified Nurse Aide | Named in transfer and infection control deficiencies |
| Dietician | Named in food service and kitchen sanitation deficiencies | |
| NA A | Nurse Aide | Named in infection control deficiencies |
| CNA G | Certified Nurse Aide | Named in transfer deficiencies |
Inspection Report
Routine
Census: 68
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident care, including activities of daily living assistance and food service quality.
Findings
The facility failed to ensure dependent residents received adequate assistance with activities of daily living such as perineal care, showers, and shaving. Additionally, the facility failed to serve food at safe and appetizing temperatures, with multiple residents reporting cold or burnt food.
Deficiencies (2)
Failure to provide complete perineal care, AM care, showers, and shaving to dependent residents.
Failure to serve food that was palatable, attractive, and at a safe and appetizing temperature, including serving burnt and cold food to residents.
Report Facts
Facility census: 68
Showers received: 5
Showers received: 3
Showers received: 5
Food temperature: 117.6
Food temperature: 118.5
Food temperature: 120.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in findings related to inadequate perineal care and resident hygiene |
| CNA B | Certified Nurse Aide | Named in findings related to shaving and nail care deficiencies |
| Dietary Aide B | Dietary Aide | Named in findings related to food temperature monitoring and serving burnt food |
| Dietary Manager | Dietary Manager | Named in findings related to food temperature monitoring and food quality |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for resident care and hygiene |
| Administrator | Administrator | Interviewed regarding expectations for resident care and food service |
Inspection Report
Life Safety
Census: 68
Capacity: 120
Deficiencies: 8
Date: Jul 8, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including maintaining fire-rated walls and doors, testing and maintaining the fire alarm system, maintaining smoke detection, sprinkler system inspections, HVAC operation, smoking regulations, and electrical equipment safety. The deficiencies had the potential to affect all residents.
Deficiencies (8)
K161 Building Construction Type and Height: The facility failed to maintain the one-hour fire rating of the ceiling and walls, leaving exposed wood studs behind a door in the ice machine hallway.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to test one fire alarm system as required, lacking a semi-annual fire alarm inspection record.
K347 Smoke Detection: Facility staff failed to maintain smoke detection in the exit corridor, leaving the Nurse TV area open and unprotected.
K353 Sprinkler System - Maintenance and Testing: The facility failed to inspect and maintain the sprinkler system quarterly as required, missing one quarterly inspection.
K363 Corridor - Doors: The facility failed to maintain corridor doors to resist smoke passage, including a door to the kitchen with a 1 inch gap allowing smoke movement.
K521 HVAC: The heating, ventilation, and air conditioning system failed to maintain proper air temperatures in the laundry area, with staff reporting excessive heat.
K741 Smoking Regulations: The facility failed to ensure cigarettes were not intermixed with combustible trash in the designated smoking area, posing a fire hazard.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed improper use of power strips and extension cords in resident rooms, violating electrical safety standards.
Report Facts
Facility census: 68
Facility capacity: 120
Date of survey: Jul 8, 2024
Inspection Report
Life Safety
Census: 60
Capacity: 120
Deficiencies: 11
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and emergency preparedness requirements at Valley Manor and Rehabilitation Center.
Findings
The facility was found deficient in emergency preparedness communication plans and multiple life safety code requirements including fire hazards, door locks, corridor requirements, exit signage, smoke barriers, and fire stop products. These deficiencies had the potential to affect all residents and occupants.
Deficiencies (11)
E029 Development of Communication Plan. The facility failed to develop and maintain a current emergency preparedness communication plan with primary and alternate means for external communication.
K100 General Requirements - Other. The facility failed to ensure free of fire hazards in physical therapy and activities rooms, including improper storage on stovetops.
K222 Egress Doors. The facility failed to utilize accepted locking arrangements and maintain appropriate signage on delayed egress doors, affecting resident safety.
K293 Exit Signage. The facility failed to maintain proper records and testing of internally illuminated exit signs with battery backup.
K372 Smoke Barrier Construction. The facility failed to maintain smoke barrier walls, including unsealed penetrations and use of drywall mud instead of approved fire stop products.
A2003 No Fire Hazard. The building presented fire hazards as referenced in K100.
A2041 Door Locks. Door locks did not meet NFPA 101 requirements; only one lock permitted per door.
A2046 Corridor Requirements. Corridors were obstructed and doors to resident rooms improperly swung into corridors.
A2049 Exit Sign-Maintain/Illuminate. Exit signs were not clearly legible or electrically illuminated at all times.
A2054 Smoke Section Walls/Doors. Smoke barriers were not maintained to required fire resistance ratings and automatic door closures were deficient.
A3001 Substantially Constructed/Maintained. The building was not maintained in good repair as required by code.
Report Facts
Deficiencies cited: 11
Census: 60
Total Capacity: 120
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 5
Date: Feb 23, 2023
Visit Reason
The inspection was conducted based on complaints alleging deficiencies in resident rights, reasonable accommodations, medication error rates, and food safety at Valley Manor and Rehabilitation Center.
Complaint Details
The complaint investigation substantiated multiple deficiencies related to resident dignity, reasonable accommodations, medication error rates, and food safety violations.
Findings
The facility failed to ensure residents were treated with dignity and respect, did not provide reasonable accommodations for resident needs and preferences, had a medication error rate exceeding 5%, and failed to maintain food safety standards including proper labeling and storage.
Deficiencies (5)
F550 Resident Rights: The facility failed to ensure staff treated residents with dignity and respect during assistance with eating, affecting three of 15 sampled residents.
F558 Reasonable Accommodations Needs/Preferences: The facility failed to honor preferences for showers and bedtime snacks for multiple residents, and did not ensure residents received services with reasonable accommodation.
F569 Notice and Conveyance of Personal Funds: The facility failed to notify residents when their Medicaid benefits account balances reached the SSI resource limit, affecting one resident.
F759 Free of Medication Error Rates 5 Percent or More: The facility had a medication error rate of 14.29%, exceeding the 5% threshold, affecting two of 15 sampled residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to ensure food was prepared and stored under sanitary conditions, including unlabeled, undated, and improperly stored food items.
Report Facts
Facility census: 60
Medication error rate: 14.29
Medication errors: 4
Medication opportunities: 28
Residents sampled: 15
Inspection Report
Census: 60
Deficiencies: 5
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, preferences for bathing and snacks, resident trust fund management, medication administration, and food safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding assistance, failure to honor residents' bathing and snack preferences, failure to notify a resident or responsible party when trust fund balance exceeded SSI limits, medication administration errors including improper eye drop technique, and failure to maintain proper food labeling, dating, and sanitary food handling practices.
Deficiencies (5)
Staff failed to ensure residents were treated with dignity when assisting with eating by standing rather than sitting, affecting three residents.
Facility failed to honor residents' preferences for at least two showers per week and failed to provide bedtime snacks as ordered for several residents.
Facility failed to notify resident or responsible party when resident's trust fund balance exceeded Supplemental Security Income resource limit.
Medication administration errors occurred with a 14.29% error rate, including improper eye drop technique such as touching the dropper tip to the eye and inadequate lacrimal pressure application.
Food items were not properly labeled, dated, or sealed; food safety practices including handwashing and glove use were inadequate in the kitchen.
Report Facts
Medication errors: 4
Residents affected by dignity deficiency: 3
Residents affected by bathing/snack deficiency: 4
Resident trust fund balance: 6557.25
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Named in medication error finding related to improper eye drop administration. | |
| Certified Medication Technician C | Named in medication error finding related to improper eye drop administration. | |
| Certified Medication Technician D | Interviewed regarding medication administration and snack distribution. | |
| Nurse Aide A | Interviewed regarding feeding assistance and showering practices. | |
| Certified Nurse Aide B | Interviewed regarding shower assignments and snack distribution. | |
| CNA C | Interviewed regarding shower assignments. | |
| CNA D | Interviewed regarding shower assignments. | |
| Director of Nursing | Director of Nursing | Interviewed regarding feeding assistance, showering, snack provision, and medication administration policies. |
| Business Office Manager | Business Office Manager | Interviewed regarding resident trust fund management. |
| Dietary Manager | Dietary Manager | Interviewed regarding food labeling, dating, and handwashing practices. |
| Dish Aide A | Interviewed regarding food preparation and labeling practices. | |
| Cook B | Observed and interviewed regarding handwashing and trash handling practices. |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and 42 CFR 483.73 regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted between December 10, 2020 and December 20, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 4
Date: Nov 23, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to restorative nursing services and food safety at Valley Manor and Rehabilitation Center.
Findings
The facility failed to ensure restorative nursing services were maintained according to therapy recommendations for residents with limited mobility. Additionally, the facility failed to maintain appropriate food temperatures for hot food served to residents.
Deficiencies (4)
F688: The facility did not ensure restorative nursing services were maintained to prevent decline in range of motion and mobility for three sampled residents. Documentation and provision of restorative therapy services were lacking.
F804: The facility failed to maintain appropriate food temperatures for hot food, serving some items cold or below required temperatures. Food safety guidelines were not consistently followed.
A4080: Facilities shall provide each resident with restorative nursing to encourage independence and mobility. This regulation was not met as evidenced by F688.
A7036: Food shall be served at safe temperatures of at least 120°F for hot foods and 45°F or below for cold foods. This regulation was not met as evidenced by F804.
Report Facts
Facility census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Hasenbeck | UNHA | Signed the statement of deficiencies and plan of correction |
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 2
Date: Jan 8, 2020
Visit Reason
The inspection was conducted to assess compliance with environmental conditions related to safety, sanitation, and comfort for residents, staff, and the public, specifically addressing issues with black mold-like substances and stained ceiling tiles.
Findings
The facility failed to provide a safe, functional, sanitary, and comfortable environment due to black mold-like substances and stained ceiling tiles in multiple resident restrooms and the therapy gym restroom. Staff were unaware or had not addressed these issues, and maintenance had not replaced or repaired stained ceiling tiles for months.
Deficiencies (2)
F 921: The facility failed to provide a safe, functional, sanitary, and comfortable environment as evidenced by black mold-like substances and stained ceiling tiles in resident restrooms and the therapy gym restroom. Staff did not monitor or address these conditions promptly.
A6015: Walls, ceilings, doors, and windows were not clean and maintained in good repair as evidenced by stained ceiling tiles and mold-like substances. Refer to F 921 for details.
Report Facts
Facility census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doreen Koenbeck | Administrator | Signed the plan of correction and is mentioned in the report |
| Maintenance Supervisor | Mentioned in relation to stained ceiling tiles and mold observations but no full name provided | |
| Housekeeping Supervisor | Mentioned in relation to awareness of mold-like substances but no full name provided | |
| Rehab Therapy Coordinator | Interviewed regarding mold-like substance in therapy gym restroom ceiling |
Inspection Report
Life Safety
Census: 61
Capacity: 120
Deficiencies: 18
Date: Jan 8, 2020
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and building construction regulations at Valley Manor and Rehabilitation Center.
Findings
The facility failed to maintain the one-hour fire rating of ceilings, emergency lighting, hazardous area protections, kitchen hood inspections, fire alarm system maintenance, sprinkler system testing, corridor wall integrity, door fire resistance, fire drills, and safe use of power strips. Multiple deficiencies were identified that could affect resident safety and emergency preparedness.
Deficiencies (18)
K161 Building Construction Type and Height: Facility failed to maintain the one-hour fire rating of ceilings with holes and openings allowing smoke travel in multiple areas. This affected four of eight smoke compartments.
K291 Emergency Lighting: Facility failed to ensure all emergency lighting was inspected and functioning, with bulbs not lighting in key exit areas.
K321 Hazardous Areas - Enclosure: Facility failed to provide hazardous protection from combustible storage in multiple areas, affecting one of eight smoke compartments.
K324 Cooking Facilities: Facility failed to have kitchen range hood suppression system inspected at least every six months, affecting one of eight smoke compartments.
K345 Fire Alarm System - Testing and Maintenance: Facility failed to maintain complete documentation of smoke detector sensitivity testing, affecting fire alarm reliability.
K353 Sprinkler System - Maintenance and Testing: Facility failed to maintain documentation of five-year sprinkler obstruction testing, affecting sprinkler system reliability.
K362 Corridors - Construction of Walls: Facility failed to maintain corridor separation walls free of penetrations, allowing smoke passage in three of eight smoke compartments.
K363 Corridor - Doors: Facility failed to maintain corridor doors resistant to smoke passage, with doors not sealing properly and gaps present, affecting four of eight smoke compartments.
K712 Fire Drills: Facility failed to conduct fire drills at varied times monthly as required, affecting staff readiness.
K920 Electrical Equipment - Power Cords and Extension Cords: Facility failed to ensure safe use of power strips and extension cords, affecting five of eight smoke compartments.
A2008 Hazardous Areas: Facility failed to provide required fire-resistant construction or automatic sprinkler protection for hazardous areas, referenced to K321.
A2017 Range Hood Certification: Facility failed to maintain required range hood certification and testing, referenced to K324.
A2019 Fire Alarm System-Test/Maintain: Facility failed to maintain complete fire alarm system testing and maintenance documentation, referenced to K345.
A2034 Sprinkler System-Test/Maintain: Facility failed to maintain sprinkler system testing and maintenance documentation, referenced to K353.
A2050 Emergency Lighting: Facility failed to maintain emergency lighting in accordance with requirements, referenced to K291.
A3001 Substantially Constructed/Maintained: Facility failed to maintain building in good repair, referenced to K161, K362, and K363.
A3013 Oxygen System Installation, Labeling: Facility failed to properly label and store oxygen cylinders, referenced to K923.
A3037 Extension Cords/Duplex Receptacles: Facility failed to ensure extension cords were UL-approved and used safely, referenced to K920.
Report Facts
Facility Capacity: 120
Resident Census: 61
Deficiencies cited: 16
Inspection Report
Routine
Census: 61
Deficiencies: 2
Date: Jan 8, 2020
Visit Reason
The inspection was conducted to assess the safety, cleanliness, and comfort of the nursing home environment, specifically focusing on the presence of black substances and stained ceiling tiles in various areas of the facility.
Findings
The facility failed to provide a safe, functional, sanitary, and comfortable environment by not identifying and addressing black mold-like substances on restroom ceilings and stained ceiling tiles in multiple locations. Staff were unaware of these issues, and the Maintenance Supervisor and Administrator acknowledged the need for immediate correction and improved monitoring.
Deficiencies (2)
Failure to identify and address black substance (mold-like) on restroom ceilings.
Failure to address stained ceiling tiles in multiple areas including corridors and dining room.
Report Facts
Facility census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Unaware of black mold-like substance on restroom ceilings until discovered during inspection | |
| Maintenance Supervisor | Supervisor (MS) | Acknowledged stained ceiling tiles and mold-like substance, noted lack of monitoring |
| Administrator | Administrator | Stated staff should monitor ceilings and address black substance immediately |
Inspection Report
Plan of Correction
Census: 49
Deficiencies: 4
Date: Apr 25, 2019
Visit Reason
The inspection was conducted to identify deficiencies related to Medicaid/Medicare coverage notices, urinary tract infection prevention, food safety, and environmental conditions at Valley Manor and Rehabilitation Center.
Findings
The facility failed to issue required notices to Medicaid residents, did not provide adequate care to prevent urinary tract infections for residents with catheters, failed to maintain food safety standards in the kitchen, and did not maintain a safe parking lot environment.
Deficiencies (4)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) to residents within required timeframes.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide appropriate care to prevent urinary tract infections for a resident with an indwelling catheter and history of UTIs.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store, prepare, and serve food according to professional food safety standards, resulting in unsanitary kitchen conditions.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain a safe parking lot with hazardous potholes, posing risks to residents and staff.
Report Facts
Census: 49
Sampled residents: 13
Sampled residents: 3
Inspection Report
Life Safety
Census: 49
Capacity: 120
Deficiencies: 5
Date: Apr 25, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Prevention Association and related regulations, focusing on exit discharge, corridor doors, and emergency power systems.
Findings
The facility failed to maintain exit discharge pathways free of obstruction and safe for residents, visitors, and staff. Corridor doors were obstructed and had improper locking mechanisms, and the emergency power system plan was inadequate to ensure power availability during emergencies.
Deficiencies (5)
K271 Discharge from exits was unsafe due to damaged cement creating trip hazards and obstructed exit egress pathways. Residents with wheelchairs and walkers could get stuck in the cracks.
K363 Corridor doors were obstructed and had dead bolt locks that delayed exit egress, violating fire safety requirements for door latching and unlocking mechanisms.
A2037 The facility did not meet exit requirements for having at least two unobstructed exits remote from each other, with one exit leading directly outside at grade level.
A2041 Door locks did not comply with regulations requiring locks to be operable from the inside by a simple device; multiple locks delayed emergency egress.
E041 The emergency power system plan was inadequate, lacking immediate emergency electrical power needed for medical equipment and sheltering in place during power loss.
Report Facts
Facility capacity: 120
Resident census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Hasenbeck | Administrator | Signed the report and plan of correction |
| Maintenance Supervisor | Interviewed regarding exit discharge and door lock issues |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 6
Date: Aug 16, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident care, infection control, and safety at Valley Manor and Rehabilitation Center.
Findings
The facility was found deficient in ensuring residents' rights to make treatment decisions, proper catheter care to prevent urinary tract infections, infection prevention and control practices, and adherence to policies regarding resident safety and hygiene. Several residents were affected by these deficiencies.
Deficiencies (6)
F552 Right to be Informed/Make Treatment Decisions. The facility failed to ensure one resident was allowed to choose a bedside commode instead of a bedpan, violating the resident's rights.
F690 Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide proper catheter care to prevent urinary tract infections for two residents, resulting in UTIs.
F880 Infection Prevention & Control. The facility failed to ensure staff followed proper infection control procedures, including hand hygiene and dressing changes, affecting multiple residents.
A4074 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4085 Infection Control/Communicable Disease. The facility failed to use acceptable infection control procedures to prevent the spread of infection and report communicable diseases timely.
A8042 Resident Lives Not Regulated/Controlled. The facility failed to ensure residents' personal lives were not regulated beyond reasonable adherence to policies, affecting resident safety.
Report Facts
Facility census: 53
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doreen Hasenbeck | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Director of Nursing | Named in findings related to catheter care and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2018
Visit Reason
The inspection was conducted as a full survey and complaint investigation for Valley Manor and Rehabilitation Center.
Complaint Details
The complaint investigation found no deficiencies and no state licensure deficiencies were cited.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection and complaint investigation.
Inspection Report
Life Safety
Census: 57
Capacity: 120
Deficiencies: 4
Date: Feb 20, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to provide a self-closure device on an oxygen storage room door and failed to install smoke detectors in two rooms open to the corridor. These deficiencies had the potential to affect all residents.
Deficiencies (4)
K321 Hazardous Areas - The facility failed to provide a self-closure device on one hazardous storage room door, affecting 15 residents. This deficiency violates NFPA 101 requirements for fire barriers and self-closing doors.
K361 Corridors - The facility failed to install smoke detectors in the Transitions Unit dining room and the 300 hall Assisted Dining Room, which are open to the corridor. This deficiency affects all residents and violates NFPA 101 corridor space requirements.
A2008 Hazardous Areas - Hazardous areas are not separated by required fire-resistant construction or automatic closing doors as referenced in K321.
A3001 Substantially Constructed/Maintained - The building is not maintained in good repair according to construction standards, referencing K361.
Report Facts
Facility capacity: 120
Resident census: 57
Affected residents: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doreen L Hoosenbeck | Administrator | Signed the statement of deficiencies and plan of correction |
| Maintenance Supervisor | Interviewed regarding deficiencies but no full name provided |
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