Madison Valley Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foods were dated and labeled when opened, disposed of when expired, and failed to maintain a clean kitchen environment. This failure increased the risk of unsanitary conditions and foodborne illnesses, for individuals consuming food stored in the facility kitchen and resident refrigerator, and from food prepared in the facility kitchen. Findings include: 1. Unlabeled/Undated/Expired Foods During an observation on 5/5/25 at 1:03 p.m., the following items were seen in the dry storage area: - one bag of vermicelli pasta, open and undated, - one box of vanilla maple cereal, open and undated, - one box of Jello mix, expiration date of 2022, - one box of Jello mix, expiration date of 2023, - one bottle of Karo corn syrup, best by date of 2024, - one bag of opened Chile de arbol powder, best by date of 7/1/23, - one open and undated bag of Knorr vegetable recipe mix, best by date of 2023, - one box of Honey Maid graham crackers, best by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one of the freezers was adequately maintained, in safe operating condition, in the kitchen. This failure increased the risk of foodborne illnesses for individuals consuming food prepared from the facility kitchen. Findings include: During an observation on 5/5/25 at 1:33 p.m., the bottom level shelves of the kitchen entry way freezer had two cardboard signs reading, Do Not Use. Food items were stored on all shelves of the freezer except the bottom level. During an interview on 5/7/25 at 2:56 p.m., staff member F stated there were plans to renovate and remodel the kitchen. Staff member F stated the freezer needed to be replaced. Staff member F stated it had been put on hold due to the planned renovation and remodel of the kitchen. Staff member F stated the cardboard signs reading Do Not Use were placed on the entry way bottom shelf of the freezer to remind staff not to put food items there. Staff member F stated when items were placed there, it caused freezer burn. This resulted in food sometimes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to perform and document a complete resident assessment prior to the use of bed rails as a restraint for 1 (#7); failed to complete and document a resident assessment prior to the use of a scoop mattress for 1 (#17); and failed to perform and document ongoing monitoring of the appropriate use of assistive devices which could be considered a restraint for 2 (#14 and #17) of 15 sampled residents. These failures increase the risk of injury for the residents. Findings include: 1. During an observation and interview on 5/5/25 at 2:04 p.m., resident #7 was in his room seated in his wheelchair. The resident's bed was noted to have upper half bed rails placed and pulled up on both sides of the bed. Resident #7 stated he used the bed rails a lot. Resident #7 stated his left side was paralyzed from a stroke. The second and third fingers of his left hand were contracted with limited range of motion. During an observation and interview on 5/7/25 at 1:32 p.m., resident #7 was seated in his wheelchair next to his bed. Both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident's representative was notified regarding a fall, a urinary tract infection, and the administration of antibiotics for 1 (#14) of 15 sampled residents. Findings include: During an interview on 5/5/25 at 3:55 p.m., NF4 stated she was frustrated the facility failed to notify her immediately when resident #14 sustained a fall with injury on 3/30/25 at 2:58 a.m., and NF4 stated she was not notified when resident #14 was diagnosed with a urinary tract infection on 4/14/25 and started on antibiotics. Review of resident #14's nursing progress note, dated 3/30/25 at 2:58 a.m., showed the resident had an unwitnessed fall and sustained a skin tear on the back of her right hand and right wrist. The note also showed resident #14 had bruising from her right elbow to her forearm, and down the back of her right hand. The note failed to show the resident's representative was notified regarding the fall with injury. During an interview on 5/8/25 at 8:02 a.m., staff member D stated the nursing staff handled notifying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to develop, implement, and operationalize a facility policy and procedure for grievances, and ensure grievance information was readily accessible, to include the name and contact information for the grievance official; failed to provide residents with readily available grievance forms for 1 (#18) of 15 sampled residents and failed to provide residents with the option to file grievances anonymously. Findings include: During an observation on 5/8/25 at 8:37 a.m., a walk-through of the facility's common areas was conducted. A resident information board was located at the front entrance to the facility which was enclosed in glass. No documentation was observed on how a resident could file a grievance. Grievance forms were found in one location, in a wall mounted clear file folder, next to the nurse's station. A wingback chair was in front of the wall mounted clear file folder containing grievance forms. No posting of the name and contact information of the grievance official was found, and no secure receptacle or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure assistive devices were not coded incorrectly as restraints for 2 (#s 14 and 17) of 15 sampled residents. Findings include: 1. During an observation and interview on 5/7/25 at 11:56 a.m., resident #17 was seen up in her wheelchair out in the hallway. Resident #17 stated she has had the scoop mattress since she was admitted (2/6/24). Resident #17 stated she has been working with therapy to learn how to get out of bed on her own and stated the scoop mattress did not restrict her movement while in bed. No bed rails were seen on the resident's bed. During an observation on 5/7/25 at 12:55 p.m., resident #17 demonstrated her ability to turn to her side and sit up on the edge of the bed, independently, thereby demonstrating the scoop mattress did not limit the resident's freedom of movement and was not considered a restraint. Review of resident #17's Assistive Device/Restraint evaluation, dated 5/6/25, showed the resident was using a scoop mattress because of poor body core control. The evaluation also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to perform and document a complete resident assessment for the use of bed rails as a restraint for 1 (#7) of 15 sampled residents. This failure placed the resident at increased risk for injury related to the use of bed rails which met the definition of a restraint. Findings include: During an observation and interview on 5/5/25 at 2:04 p.m., resident #7 was in his room seated in his wheelchair. The resident's bed was noted to have bed rails on both sides of the bed in the up position. Resident #7 stated he used the bed rails a lot. Resident #7 stated his left side was paralyzed from a stroke. The second and third fingers of his left hand were contracted with limited range of motion. During an observation and interview on 5/7/25 at 1:32 p.m., resident #7 was seated in his wheelchair next to his bed. The bed rails were seen in the up position. When asked to lower the left bed rail, resident #7 was unable to pull the pin so the rail could be lowered. The resident stated he did not have the strength or coordination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure competent nursing staff were able to provide nursing service for on time medication administration for 1 (#8), and failed to meet a resident's physical and psychosocial needs, for 1 (#16) of 15 sampled residents. Findings include: 1. During an interview on 5/6/25 at 9:08 a.m., resident #16 stated there had been an issue with a travel nurse who had an attitude. Resident #16 stated the nurse was gone after only a few days. Resident #16 stated other residents had voiced concern and complained about the same travel nurse and had issues with the nurse's attitude and timeliness of completing care. Resident #16 was hesitant to provide additional detail regarding specific incidents. During an interview on 5/8/25 at 11:08 a.m., staff member B stated she was responsible for covering any call-offs by nurses. Staff member B stated she helped cover for medication passes if a traveler needed assistance. This was to help avoid medications being administered late. Staff member B stated she was on-call and available all the time.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a hospice resident's pain was managed effectively and consistently, to lessen a resident's intermittent pain level, for 1 (#11) of 15 sampled residents. This increased the risk of causing unnecessary pain and/or discomfort. Findings include: During an observation and interview on 5/6/25 at 3:08 p.m., NF6 was sitting in a chair beside resident #11's recliner, holding resident #11's hand as resident #11 was resting. NF6 stated resident #11 received a regular dose of ibuprofen and Tylenol per hospice orders. NF6 stated she had a concern with nurses not giving morphine for pain relief until waiting one full hour for the dose of ibuprofen or Tylenol to kick in. NF6 stated resident #11 did not take medications for anxiety or any other psychotropics to assist with comfort needs. NF6 stated resident #11 had never taken many types of medications for pain, and did not always ask for pain medication. NF6 stated she spoke with staff member B about the pain medication timing. NF6 stated pain medication and its…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to have a system in place to ensure temporary agency staff were trained on the facility's infection prevention and control program standards, policies, and procedures. This deficient practice had the potential to affect residents who worked with or were affected by the untrained staff. Findings include: During an interview on 9/9/24 at 10:19 a.m., staff member C stated she had been employed at the facility as a traveling CNA for approximately six months. She stated infection control training was not included in her on-board training at the facility. During an observation on 9/9/24 at 10:28 a.m., staff member C failed to perform proper infection control practices related to hand hygiene (See F880). During an interview on 9/9/24 at 12:10 p.m., staff member E stated she educated staff on infection prevention and control practices annually and during orientation of new employees. During an interview on 9/9/24 at 1:10 p.m., staff member D stated she was hired as a traveling employee in the middle of August 2024. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, staff member C failed to adhere to standard precautions, related to the use of personal protective equipment and hand hygiene, while providing personal care for 1 (#1) of 9 sampled residents residing in the facility. Findings include: During an observation on 9/9/24 at 10:26 a.m., staff member C donned gloves and entered resident #1's room. Staff member C did not sanitize her hands before donning the clean gloves. During an observation on 9/9/24 at 10:28 a.m., staff member C and staff member D assisted resident #1 with repositioning. Staff member C removed resident #1's soiled incontinence brief and cleaned loose stool from the resident's peri area, then disposed of the brief in the garbage can. Staff member C did not remove the dirty gloves. Staff member C preceeded to assist staff member D with placing the Hoyer lift sling under resident #1, removed the resident's clothing she was wearing, and put on clean clothing. Staff member C, still wearing the dirty gloves, placed a clean incontinence brief back into resident #1's clothing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure MDS assessments were coded correctly for diagnoses for 1 (#5); and for bed rails for 3 (#s 8, 12, and 13) of 12 sampled residents for MDS accuracy. Findings include: 1. Review of resident #5's Physician Office Clinic Note, dated 3/18/24, showed the physician added the diagnosis of Dementia under the section, Assessment/Plan. Review of resident #5's Quarterly MDS, with an ARD of 4/17/24, failed to show a diagnosis of Dementia on the assessment. The assessment had not been revised to show the new diagnosis of dementia. Review of resident #5's EMR showed documentation of a request to add Dementia to the resident's diagnosis list on 5/6/24, the first day of the survey. During an interview on 5/7/24 at 11:13 a.m., staff member F stated resident #5 definitely had a diagnosis of Dementia. During an interview on 5/7/24 at 2:35 p.m., staff member D stated to add a diagnosis to resident #5's diagnosis list, the provider needed to sign a form, or it needed to be discussed during medication reviews. Staff member D…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to revise care plans to reflect the medical status for 1 (#9) resident; and to reflect bed rail usage for 1 (#16) of 12 sampled residents for care plans. This had the potential to cause staff to provide inaccurate care to the residents. Findings include: 1. Review of resident #9's physician's order, with a discontinued date of 4/12/24, showed, blood glucose check. Notify provider if greater than 400. Review of resident #9's comprehensive care plan, with a revision date of 5/6/24, showed, continue monitoring blood sugars as ordered. Review of resident #9's MAR showed resident #9's blood sugar had not been checked since 4/12/24. During an interview on 5/8/24 at 7:35 a.m., staff member F stated, We haven't been checking resident #9's blood sugar because hospice discontinued them. 2. During an observation on 5/7/24 at 11:36 a.m., resident #9 was observed in a wheelchair in the Day Room. During an observation on 5/7/24 at 1:14 p.m., resident #9 was observed in a wheelchair in the dining room. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to implement the intervention of bed rails and update the care plan for use of the rails, for 1 (#16) of 5 sampled residents with bed rails. Findings include: During an observation on 5/6/24 at 3:05 p.m., resident #16 was sleeping in his bed. There were no bed rails on the bed. During an observation on 5/7/24 at 2:20 p.m., resident #16 was up in his wheelchair. Resident #16 did not have bed rails present on his bed. Review of resident #16's physician orders, dated 10/24/23, showed, .use of right bed side rail for bed mobility and repositioning to enhance independence, not being used as restraint . Review of resident #16's paper Care Plan, in a binder labeled, 'Hall1,' dated 2/28/24, showed, Side rail on bed per [Resident #16's] request; left side rail not being used as restraint method. During an interview on 5/7/24 at 3:23 p.m., staff member H stated she did not think resident #16 had bed rails, then she looked in the resident's EMR and stated it looked like there was an order for a bed rail. Staff member H stated resident #16…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.