Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Manor Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Unsafe and unclean conditions were observed on multiple nursing units and in a resident-used exterior area. A room had heavily marred walls and holes behind the bed, a bathing suite toilet room had a towel with a brown substance on a plunger, another room had stained flooring, another had cracked walls and a cracked built-in dresser, and a shared sink area had a broken paper towel dispenser. The rear smoking area also had holes and uneven ground, and the Administrator confirmed the issues.
Unsafe and Unclean Resident Environment: Surveyors observed multiple environmental and equipment issues across several units, including missing floor tiles, stained refrigerator shelves, loose bathroom handrails, stained privacy curtains, damaged curtain rods, broken furniture drawers, stained floors and ceiling tiles, a dirty urine collection container, holes and marred walls, an empty soap dispenser, and a bathtub with a brown and yellow substance near the drain. The Administrator confirmed the issues were present.
Failure to document ordered wound care was identified for two residents with pressure sores. One resident with Alzheimer's disease had a right buttock wound and sacral slit, and another resident with diabetes had a sacral pressure ulcer; both care plans called for treatments as ordered by the MD. The TAR showed multiple missed or undocumented dressing and cleansing treatments on day and evening shifts, and the DON confirmed there was no documented evidence the treatments were completed as ordered.
Failure to follow medication orders and monitoring parameters affected several residents. One resident received midodrine outside SBP limits, another received amlodipine when SBP was too low, and a third received midodrine when SBP was above the ordered threshold. A resident with seizure disorder did not have an ordered levetiracetam level obtained, and a resident with constipation and dementia did not receive PRN constipation meds until seven days after the last documented BM. The DON confirmed the order deviations and missed lab test.
Failure to Assess and Care Plan for PTSD: The facility did not assess three residents with PTSD for symptoms or triggers and did not develop individualized, person-centered care plans to address trauma history or minimize re-traumatization. One resident had PTSD along with schizoaffective disorder and early onset Alzheimer's disease, another had PTSD and anxiety, and a third had PTSD and major depressive disorder with documented anxiety, vomiting, and worsening cognitive and emotional symptoms. The DON confirmed the residents were not assessed or care planned for PTSD.
Missing Controlled Substance Shift Counts: The facility failed to maintain accurate controlled substance reconciliation records on the 400 Unit med cart. Facility policy required two licensed nurses to complete and sign the Shift Count at each shift change, but the log had numerous missing signatures from both the oncoming and off-going nurses across multiple shifts, and the DON confirmed the signatures were absent as required.
Failure to send transfer notices to the Ombudsman: The facility did not document that written transfer notices were sent to a representative of the Office of the State LTC Ombudsman for five residents who were transferred to the hospital after changes in condition. The DON confirmed that the notices were not sent.
A resident with multiple medical conditions, including an internal cardioverter/defibrillator, did not have care plan interventions documented for monitoring and care of the device, despite this need being identified in the assessment.
A resident with dementia, diabetes, and end stage renal disease, who required extensive assistance, did not have geri sleeves applied to both arms as ordered by the physician. Multiple observations showed the resident in bed without the required arm protectors, indicating staff did not follow the physician's instructions.
Two cognitively impaired residents with multiple medical conditions were not provided with required floor mats as specified in their care plans to prevent falls. Despite documented incidents of falls and clear care plan instructions, staff failed to place mats on both sides of the bed while the residents were in bed, as confirmed by observations and staff interview.
The facility did not ensure the kitchen suppression system was inspected and serviced at required intervals. During a document review, it was found that the facility could not provide documentation for two required inspections in the prior year, with only one inspection report available. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain its fire alarm system, affecting the entire facility. Issues included an untested pull station due to missing keys, undocumented smoke detector sensitivity values in the basement, and detectors in Zone 4 not resetting automatically. An exit interview confirmed these deficiencies were unresolved, and the facility lacked documentation for basement smoke detector sensitivity testing.
The facility failed to maintain its sprinkler system, affecting the entire facility. Inspections revealed missing documentation, a corroded sprinkler, pending hydro tests, and low temperatures in the fire pump room risking pipe damage. Additionally, recessed sprinkler heads and a low water alert in the water tower were observed, confirming the facility's failure to ensure proper maintenance.
The facility failed to conduct fire drills once per shift per quarter, affecting the entire facility. A document review revealed missing documentation of staff participation in monthly fire drills for several months in 2024 and 2025. This deficiency was confirmed during an exit interview with the Administrator and Director of Maintenance.
The facility did not ensure that rated fire door assemblies were inspected and tested annually, as required by NFPA standards. A document review revealed the absence of documentation for inspections and tests within the past 12 months, affecting the entire facility. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility did not conduct the required annual inspection of electrical receptacles in resident care areas, affecting all resident bed locations. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
The facility failed to maintain exit egress doors with delayed egress locking arrangements, as two doors did not release after 15 seconds of pressure. This issue was confirmed by the Administrator and affected two smoke compartments.
The facility failed to maintain documentation verifying that emergency backup lights were tested monthly and that a 90-minute test was performed annually on one of its two levels. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
The facility was found to have conflicting exit signage at the Great Room entrance, with one operable sign and another disabled, leading to confusion about the correct emergency exit path. This was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility did not maintain a proper hazardous area enclosure on one level. On the first floor, the soiled utility room door across from room 312 was found with paper towels stuffed into the doorframe strike plate, preventing it from latching. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility did not maintain portable fire extinguishers as per NFPA 10, with 15 out of 32 extinguishers needing replacement. An inspection on January 17, 2025, identified the issue, but the extinguishers had not been replaced by the time of the survey. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain smoke barrier walls, as observed on the first floor above the smoke barrier doors next to the Great Room, where an unsealed MC wire penetration was found. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant. The unsealed penetration compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating.
The facility failed to maintain smoke barrier doors to close tightly and resist smoke passage due to blockage by a berri lift next to room 508. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain HVAC exhaust diffusers, as observed in the soiled utility room of the 500 wing, where a diffuser was dislodged from the ceiling and resting on cabinets. This was confirmed by the Administrator and maintenance staff.
The facility failed to maintain proper accessibility and safety of electrical panels. A supply order was stored against high voltage switch gear handles, an exposed electrical conduit was found in the kitchen, and janitorial equipment blocked access to electrical panels in a mechanical room. These issues were confirmed by facility staff.
The facility was found to be non-compliant with electrical equipment standards due to unauthorized use of power strips and extension cords. A dehumidifier was plugged into an extension cord in the basement, and a microwave, mini-fridge, and toaster were plugged into a power strip in the Admissions Office. These findings were confirmed during an exit interview with facility staff.
A propane tank was found unsecured in the basement at the outdoor dock area, stored in front of the main electrical high voltage switch gear. This deficiency was confirmed by the Administrator and Director of Maintenance, indicating a failure to adhere to NFPA 101 standards for gas equipment storage.
The facility did not comply with smoking regulations, as cigarette butts were found accumulated in mulch beds, outside resident room windows, and along the building's side driveway, outside the designated smoking area. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain an emergency preparedness training program based on the Emergency Preparedness Plan, lacking documentation of initial and annual staff training. This was confirmed during an exit interview with the Administrator and other staff.
The facility failed to maintain documentation of initial and annual Emergency Preparedness training for staff and volunteers, as revealed during a document review and confirmed in an exit interview with the Administrator and Director of Maintenance.
The facility failed to conduct the required annual full-scale exercise and an additional exercise to test the emergency preparedness plan, affecting the entire facility. Document review revealed the absence of these exercises within the previous 12 months, and the lack of documentation was confirmed by the Administrator and staff during an exit interview.
The facility failed to maintain required egress clearances, with the Northeast Stair Tower being narrower than required and the Basement Level having inadequate headroom clearance. These issues were confirmed by the facility's administration.
The facility was found to have smoke compartments exceeding the maximum allowable size of 22,500 square feet in the 400 wing and First Floor, affecting two of four smoke compartments. This was confirmed through observation, document review, and interviews with facility staff.
The facility failed to maintain required emergency generator components, as the generator set in the basement lacked battery back-up emergency lighting. This deficiency was confirmed through observation and an interview with the Administrator and maintenance staff.
The facility failed to document the rationale for extending PRN anti-anxiety medications for three residents. One resident with anxiety and major depressive disorder received Ativan PRN multiple times without proper documentation. Another resident with bipolar disorder was given Ativan PRN several times, also lacking documentation. A third resident with multiple conditions, including dementia, received Ativan gel and lorazepam PRN frequently, again without the necessary documentation. The administrator confirmed the absence of documentation for extending these PRN orders.
The facility failed to follow infection control policies, leading to deficiencies in implementing Transmission-Based and Enhanced Barrier Precautions. A resident with influenza A was not managed with proper PPE, and staff were unaware of precautionary statuses due to missing signage. Additionally, residents at risk of MDROs were not managed with required protective gowns, indicating systemic issues in infection control practices.
Valley Manor Rehabilitation and Healthcare Center was found non-compliant with regulations for a safe, clean, and homelike environment. Observations included broken fixtures, missing amenities, and structural issues across multiple rooms, such as chipped paint, broken tiles, and stained curtains, indicating a failure to maintain a comfortable environment for residents.
The facility failed to provide adequate grooming and hygiene services for two residents who required extensive assistance with ADLs. One resident with dementia and diabetes was observed with long and dirty fingernails, while another resident with a history of stroke and depression had long, dirty fingernails and an unshaved beard. Both residents were able to communicate their needs, and the Director of Nursing confirmed that their grooming needs should have been addressed.
A resident with cognitive impairment and multiple medical conditions, including atrial fibrillation and diabetes, had frostbite wounds on their lower extremities. Despite a physician's order for daily wound care, the facility failed to perform the required treatments on several occasions, as confirmed by the Nursing Home Administrator.
The facility did not meet the required nurse aide (NA) to resident ratios on three occasions within a 21-day period. Specifically, the day shift failed to maintain one NA per ten residents on two days, and the evening shift did not meet the one NA per eleven residents requirement on another day.
The facility did not meet the required NA to resident ratio during a day shift, failing to provide one NA per ten residents. This was confirmed by the DON after reviewing the nursing schedules.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident in a 24-hour period, providing only 3.17 hours on one day. This was confirmed by the DON during an interview.
Two residents in the facility were not served meals according to their preferences. A resident with anxiety and hypertension received buttered carrots despite disliking them, and another resident with heart failure and diabetes was served lemonade, which he disliked. Both residents were alert and oriented, and their meal tickets indicated their preferences, which were not followed by the dietary department.
The facility did not comply with the regulation to post menus two weeks in advance. Observations revealed that only meals for two days were posted, and the Registered Dietician confirmed that menus were not distributed to residents or posted in advance. The Nursing Home Administrator acknowledged this deficiency.
The facility did not meet the required nurse aide (NA) to resident ratios as per the regulation effective July 1, 2024. A review of nursing time schedules revealed that the facility failed to maintain the minimum NA to resident ratio during the day shift on multiple occasions and during the night shift on several dates. These deficiencies were noted over a period of seven out of 21 days reviewed.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on six occasions, with care hours ranging from 2.70 to 3.07. This was determined through a review of nursing time schedules.
A resident at high risk for elopement left the facility unattended after staff failed to respond to an alarm. The resident, who was cognitively impaired, was last seen wandering the facility and was found over three hours later, having traveled 5.5 miles away. This incident was identified as an Immediate Jeopardy situation due to inadequate supervision.
The facility failed to maintain an effective pest control program in the North unit, as flies were observed in the hallway and several rooms. The Administrator confirmed the presence of flies, indicating a lapse in pest control measures.
The facility failed to prevent and report resident-to-resident physical abuse involving a resident with a history of behavioral disturbances. Two incidents occurred where the resident pushed other residents, causing harm. These incidents were not reported to the State Licensing Agency as required by facility policy.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment on three nursing units and in the rear exterior area used by residents. During observation, a room had heavily marred walls with chipped paint and three holes behind bed A, the 400-unit bathing suite toilet room contained a towel with a brown substance placed on top of a toilet plunger, another room had flooring stained with a dark black residue, another room had a cracked wall near the shared bathroom and a built-in dresser with cracks along the side, and a room had a broken paper towel dispenser for the shared sink. The rear exterior of the facility also had holes and uneven spots on the ground near the smoking area. The Administrator confirmed the environmental issues were present.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to maintain resident environments and equipment in a sanitary and homelike manner on four of six nursing units, including units 200, 400, 500, and 600. Surveyors observed a missing block of floor tiles at the entrance to the main kitchen, juice stains on refrigerator shelves in the nourishment room behind the central 200-unit nursing station, and a shared bathroom with black spots on the floor. In resident rooms, surveyors found very loose over-the-toilet handrails, a privacy curtain with a large stain, curtain rod screws coming out of the wall with the rod partially hanging, yellow spots on the floor, brown stains on a tube feeding pole, drawers off track and on the floor, broken dresser drawers, dark brown spots in a bathroom with a dirty urine collection container on the floor, unpainted spackle on the wall, black marks on the ceiling, and walls marred and scratched near a window. Additional observations included the 400-unit bathing suite with stained ceiling tiles, a bathtub with a brown and yellow substance near the drain, continuously running water from the faucet, a hole in the wall between the tub and shower room, an empty soap dispenser, stained privacy curtains, and one shower stall without a privacy curtain. Surveyors also observed two holes and marred wall surfaces in a hallway, stained ceiling tiles above a resident's bed, and brown stains at the base of a tube feeding pole. The Administrator confirmed the environmental issues were present during interview.
Failure to Document Ordered Pressure Ulcer Treatments
Penalty
Summary
Failure to provide treatment and services as ordered by the physician was identified for two residents with pressure sores. One resident with early onset Alzheimer's disease had a pressure sore on the right buttock and a scar on the coccyx; the MDS indicated substantial assistance with overall care and two pressure sores. The care plan included an actual wound on the right buttock and sacral slit with an intervention for staff to provide treatments as ordered. A physician order dated February 19, 2026 directed staff to cleanse the sacral slit with soap and water and apply Triad Paste every day and evening shift, but the TAR showed no documented evidence that the treatment was completed on the day shift on February 20 and 21, 2026, and on the evening shift on February 22, 2026. Another resident with a sacral pressure ulcer and diabetes had a wound care note documenting a pressure sore on the sacrum. The MDS indicated the resident was dependent on staff for all care and had two pressure sores. The care plan identified an actual wound on the bottom of the sacrum and included an intervention for staff to provide treatments as ordered. A physician order dated January 29, 2026 directed staff to cleanse the sacrum with an antiseptic cleansing solution and apply a collagen dressing and a calcium alginate foam dressing every day and evening shift and as needed, but the TAR showed no documented evidence that the treatment was completed on the day shift on February 2, 5, 7, and 12, 2026, and on the evening shift on February 2, 13, and 21, 2026. The DON stated in interview that there was no documented evidence the treatments had been completed as ordered.
Failure to Follow Medication Orders and Monitoring Parameters
Penalty
Summary
The facility failed to ensure physicians’ orders were implemented for five sampled residents. Resident 1 had hypotension and an order for midodrine three times daily with instructions not to give it if systolic blood pressure (SBP) was greater than 120 mm/Hg; the January and February 2026 MARs showed the medication was administered 19 times in January and 10 times in February when SBP was above that parameter. Resident 78 had hypertension and an order for amlodipine once daily with instructions not to give it if SBP was less than 110 mm/Hg; the January and February 2026 MARs showed the medication was given four times in January and three times in February when SBP was below that parameter. Resident 118 also had hypotension and an order for midodrine three times daily with instructions to administer it if SBP was less than 100 mm/Hg; the January and February 2026 MARs showed the medication was administered 60 times in January and 30 times in February when SBP was greater than 100 mm/Hg. Resident 66 had seizure disorder and traumatic subdural hemorrhage, and a physician ordered a levetiracetam blood level lab test on February 7, 2026, but there was no documented evidence that the test was completed. Resident 86 had constipation and dementia, with orders for Milk of Magnesia as needed and/or if no bowel movement in three days, followed by bisacodyl suppository and then an enema if there were no results, as well as Dulcolax as needed for constipation. Bowel movement tracking for Resident 43 showed no documented bowel movements from February 17, 2026, through February 24, 2026, and the MAR showed no as-needed constipation medication was given until a Dulcolax tablet was administered seven days after the last documented bowel movement. The DON confirmed that the medications were administered outside established parameters for Residents 1, 78, and 118, that the lab test for Resident 66 was not obtained, and that the as-needed constipation medications for Resident 86 should have been given before seven days without a documented bowel movement.
Failure to Assess and Care Plan for PTSD
Penalty
Summary
The facility failed to assess residents with a diagnosis of PTSD and failed to develop and implement individualized, person-centered care plans to provide trauma-informed care for three sampled residents. Resident 4 was admitted with diagnoses including PTSD, schizoaffective disorder, and early onset of Alzheimer's disease. The MDS indicated some memory impairment and a diagnosis of PTSD, but there was no documentation that the resident was assessed for PTSD-related symptoms or triggers, and the care plan did not include measures to address trauma history, identify triggers, or provide interventions to minimize triggers or re-traumatization. Resident 16 was admitted with diagnoses including PTSD and anxiety. The MDS showed the resident was cognitively intact and had PTSD, but there was no documentation of an assessment for PTSD symptoms or triggers, and the care plan did not address trauma history, triggers, or interventions to minimize triggers or re-traumatization. Resident 77 was admitted with diagnoses including PTSD and major depressive disorder; the MDS showed the resident was cognitively intact and had PTSD. Clinical documentation noted the resident reported bad PTSD from the Vietnam war that caused anxiety and recurring vomiting, and later notes described worsening cognitive and emotional symptoms, increased difficulty with focus and concentration, escalating anxiety, and persistent insomnia. Despite these documented concerns, there was no documentation that PTSD-related symptoms or triggers were assessed, and the care plan did not include measures to address trauma history, identify triggers, or minimize re-traumatization. The DON confirmed that Residents 4, 16, and 77 were not assessed or care planned for PTSD.
Missing Controlled Substance Shift Count Signatures
Penalty
Summary
The facility failed to maintain accurate reconciliation records for controlled substances on one of seven medication carts, specifically the 400 Unit medication cart. Facility policy required a physical inventory of all controlled medications at shift change by two licensed nurses, with the count documented on the resident’s controlled medication accountability record and on a Shift Count sheet. The Director of Nursing stated that the nurse coming on duty and the nurse going off duty were responsible for counting controlled substances and other medications with risk of abuse or diversion at each shift change and signing the Shift Count sheet to verify the count was accurate. Observation of the 400 Unit medication cart revealed that the Shift Count log had missing licensed staff signatures for multiple shifts in February 2026. Review of the log for January 5 through 24, 2026, and February 2 through 25, 2026, showed missing signatures from the coming-on-duty nurse on 21 of 44 days for the 7:00 a.m. shift, 28 of 44 days for the 3:00 p.m. shift, and 28 of 44 days for the 11:00 p.m. shift. Missing signatures from the going-off-duty nurse were documented on 27 of 44 days for the 7:00 a.m. shift, 25 of 44 days for the 3:00 p.m. shift, and 25 of 44 days for the 11:00 p.m. shift. The DON confirmed that the signatures were not present as required by facility policy.
Failure to Send Transfer Notices to the Ombudsman
Penalty
Summary
The facility failed to provide copies of written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for five residents who were transferred out of the facility. Clinical record review showed that Resident 6 was transferred to the hospital on January 31, 2026, after a change in condition, and there was no documented evidence that the transfer notice was sent to the Ombudsman. Similar record review findings were identified for Resident 11, who was transferred to the hospital on February 6, 2026, after a change in condition, with no documentation that the notice was sent. Additional record review showed that Resident 14 was transferred to the hospital on December 22, 2025, and again on January 5 and 16, 2026, after changes in condition, with no documented evidence that the transfer notice was sent to the Ombudsman. Resident 117 was transferred to the hospital on October 9, 2025, and February 7, 2026, after changes in condition, and Resident 159 was transferred to the hospital on February 1, 2026, after a change in condition; for both residents, there was no documented evidence that the facility sent a copy of the transfer notice to the Ombudsman. During an interview on February 26, 2026, at 10:30 a.m., the DON confirmed that the written copies of the transfer notices were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Cardiac Device in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all identified needs for one resident. Clinical record review showed that the resident was admitted with diagnoses including atrial fibrillation, multiple wounds, heart disease, and a skin infection, and was dependent on staff for care. The resident also had a history of surgeries, including the placement of an internal cardioverter/defibrillator. Despite this, there was no documentation that the care plan included interventions to monitor and care for the internal cardioverter/defibrillator, as identified in the comprehensive assessment.
Failure to Follow Physician's Order for Geri Sleeves
Penalty
Summary
A deficiency was identified when staff failed to implement a physician's order for a resident with dementia, diabetes, and end stage renal disease. The clinical record showed that the resident was cognitively impaired and required extensive assistance with dressing. A physician's order dated April 30, 2025, directed staff to apply geri sleeves (arm protectors) to both of the resident's arms at all times except during hygiene. However, during multiple observations on May 15, 2025, the resident was found in bed without the required geri sleeves on his arms, indicating that the physician's order was not followed.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Residents
Penalty
Summary
The facility failed to implement required safety interventions for two residents who were identified as being at risk for falls. Both residents had significant medical conditions, including dementia, diabetes, end stage renal disease, heart failure, and convulsions, and were assessed as cognitively impaired and dependent on staff for bed mobility and transfers. Their care plans specifically directed staff to place mats on the floor on both sides of the bed while the residents were in bed to prevent falls. However, clinical record reviews and facility documentation showed multiple incidents where one resident slid out of bed or was found on the floor, and observations confirmed that mats were not in place as required. On the day of the survey, both residents were observed in bed without mats on either side, contrary to their care plan interventions. The Administrator confirmed during an interview that mats should have been present. These findings were based on clinical record review, facility documentation, direct observation, and staff interview, demonstrating a failure to provide adequate supervision and implement safety measures as outlined in the residents' care plans.
Failure to Maintain Kitchen Suppression System
Penalty
Summary
The facility failed to ensure that the kitchen suppression system was inspected and serviced at the required intervals. During a document review on March 12, 2025, it was found that the facility could not provide documentation showing that the kitchen suppression system had been tested and maintained twice in the prior year, as required. Only one inspection report dated January 17, 2025, was available. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Kitchen suppression system will be tested again and two inspections completed for the year in June. 2. 4/28/25 3. Maintenance staff will conduct quarterly inspections in the kitchen. 4. The Director of maintenance will keep inspection reports and conduct monthly audits x3.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on March 12, 2025, it was found that the fire alarm annual report dated May 15, 2024, listed several issues. The pull station at the nurses' station could not be tested due to the unavailability of keys needed for resetting. Additionally, the smoke detector sensitivity values were not documented for the basement detectors, and the facility needed to contact Simplex to acquire these values. Furthermore, Zone 4 required investigation as the detectors did not automatically reset. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that these deficiencies had not been resolved. The facility also failed to provide documentation for sensitivity testing on the basement smoke detectors.
Plan Of Correction
1. Tustin Fire Alarm will be scheduled to come to the facility and complete all testing. A. Keys are now available for reset. B. Tustin visited 3/31/25 and waiting on report for basement detectors. C. Zone 4 was checked when Tustin came out. Waiting on report. 2. 4/28/25 3. Maintenance staff educated on keeping up to date with the scheduling of the fire alarm system. 4. The Director of maintenance will keep all reports up to date.
Facility Fails to Maintain Sprinkler System
Penalty
Summary
The facility failed to maintain its sprinkler system, affecting the entire facility. Documentation reviewed on March 12, 2025, revealed that only two quarterly external water tank inspections and two quarterly wet sprinkler inspections were recorded for the year 2024. During an exit interview, the Administrator, Director of Maintenance, and Assistant confirmed the absence of necessary report documentation. Additionally, the 4th quarter sprinkler inspection report from December 23, 2024, indicated several issues: a corroded sprinkler in the Dietary area needed replacement, a hydro test for the fire department connection was pending, and the fire pump room's temperature was below the required 40 degrees Fahrenheit, risking pipe damage due to potential freezing. Furthermore, the facility was advised to monitor and maintain the water level in the tank consistently. Observations made on March 12, 2025, revealed additional deficiencies. Two sprinkler heads in the basement laundry chute room were recessed into the ceiling, potentially hindering immediate water spread. Moreover, the fire alarm panel indicated a supervisory alert for low water in the water tower. These findings were confirmed during an exit interview with the facility's administration and maintenance team, highlighting the facility's failure to ensure proper maintenance and functionality of its sprinkler system.
Plan Of Correction
1. The Sprinkler system will be scheduled with Tustin for testing annually. Sprinkler heads will be adjusted. At the time of the survey, the fire pump was in test mode and was discharging water, and the facility ensures proper water is filled in the water tower. The facility will inspect the external water tank at least quarterly. 2. A. Facility will schedule replacement sprinkler with Tustin. B. Facility will contact the fire department to get hydro test scheduled. C. Report was from 2024. The temperatures were good during the site visit on 3/12/25. D. Facility currently monitors the water tank daily. E. Water was flowing during the site visit on 3/12/25. 3. Tustin will be scheduled to come in and turn sprinkler heads downwards. 4. The fire alarm panel is working properly and was completing a test which led to the low water notification. The facility has a working heater that maintains adequate temperature throughout.
Failure to Conduct Quarterly Fire Drills on Each Shift
Penalty
Summary
The facility failed to conduct fire drills once per shift per quarter, which affected the entire facility. During a document review on March 12, 2025, it was revealed that the facility could not provide accurate documentation of shift participation in monthly fire drills for several months, specifically March, May, June, August, and October of 2024, and February of 2025. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged the lack of accurate documentation.
Plan Of Correction
1. The facility will conduct fire drills immediately on all three shifts. Going forward, the facility will create a schedule for fire drills to ensure they are completed as required. 2. 4/28/25 3. The Maintenance Director was educated on conducting the fire drills once per shift per quarter and intermittently throughout the year on different dates and times. 4. The Director of maintenance will complete random audits.
Failure to Inspect and Test Fire Door Assemblies Annually
Penalty
Summary
The facility failed to ensure that rated fire door assemblies were inspected and tested annually, as required by NFPA 101 and NFPA 80 standards. During a document review conducted on March 12, 2025, it was discovered that the facility could not provide documentation proving that the rated fire door assemblies had been inspected and tested within the previous 12 months. This deficiency affects the entire facility, as confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Conducted rated fire door testing and inspection of fire doors. 2. 4/28/25 3. Maintenance staff educated on completing rated fire door testing. 4. Director of maintenance will audit fire doors quarterly.
Failure to Perform Annual Electrical Inspections
Penalty
Summary
The facility failed to maintain the required inspections of electrical wiring and receptacle systems, which affected all resident bed locations. During a documentation review on March 12, 2025, it was revealed that the annual inspection of receptacles in resident care areas was not performed. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
Facility will conduct annual receptacle testing in resident care areas. 4/28/25 Maintenance staff educated on receptacle testing. The Director of maintenance will conduct random facility audits.
Delayed Egress Door Malfunction
Penalty
Summary
The facility failed to maintain proper functioning of exit egress doors equipped with delayed egress locking arrangements. During an observation on March 12, 2025, it was noted that two exit doors did not release after 15 seconds of applying pressure against the crash bar, as required. These doors were located on the first floor, specifically door # EM-1 next to the basement stairwell and door # E4 in the dining room. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged that the doors did not release as expected. This issue affected two of the four smoke compartments in the facility, indicating a failure to comply with the necessary safety standards for egress doors.
Plan Of Correction
1. Door # EM1 repaired and released on egress and requesting a TLW for EM4 as a door repair may be necessary to be made by an outside vendor. 2. 4/28/25 3. Doors will be checked on a monthly basis. 4. Director of maintenance or designee will conduct monthly audits to ensure doors are released after 15 seconds of applying pressure.
Emergency Lighting Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper documentation for emergency lighting testing and inspection on one of its two levels. During a review conducted on March 12, 2025, it was observed that the facility did not have records verifying that emergency backup lights were tested monthly and that a 90-minute test was performed annually. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged the lack of documentation for the emergency backup lighting tests.
Plan Of Correction
1. Facility will resume testing monthly test and completed a 90-minute test. 2. 4/28/25 3. The new director of maintenance will create a new PM binder. Maintenance staff educated on testing. 4. Audits will be conducted monthly x 3.
Conflicting Exit Signage in Facility
Penalty
Summary
The facility failed to maintain proper exit signage, as observed on March 12, 2025. At the entrance to the Great Room from the corridor, there were two exit signs providing conflicting instructions for the nearest emergency exit. One sign was operable, while the other was disabled, leading to confusion about the correct exit path. This issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Exit signage corrected and operable. The other exit sign removed. 2. 4/28/25 3. Director of maintenance will check exit signs on monthly basis. 4. Audit will be conducted monthly x 3.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain a proper hazardous area enclosure on one of its two levels. During an observation on the first floor, it was noted that the soiled utility room across from room 312 had paper towels stuffed into the doorframe strike plate. This obstruction prevented the door from latching properly, compromising the integrity of the hazardous area enclosure. The issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
1. Soiled utility room door repaired to fully close and latch. 2. 4/28/25 3. Staff education completed on regulation for NFPA 101 Standard (section 8.4) stating that "doors shall be self-closing or automatic closing." 4. Director of maintenance will conduct audits monthly x 3.
Failure to Maintain Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10, affecting 15 out of 32 extinguishers. During a documentation review on March 12, 2025, it was revealed that an annual inspection had been conducted on January 17, 2025. However, the report indicated that 15 fire extinguishers required replacement. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that these extinguishers had not been replaced at the time of the survey.
Plan Of Correction
1. The facility will replace the 15 fire extinguishers. 2. 4/28/25 3. The maintenance director will be educated on tracking and replacing fire extinguishers as needed. 4. Monthly audits will be conducted on fire extinguisher expiration dates and that they are in good working condition.
Unsealed MC Wire Penetration in Smoke Barrier
Penalty
Summary
The facility failed to maintain smoke barrier walls, which is a requirement for ensuring fire safety. During an observation on March 12, 2025, at 3:00 p.m., it was noted that on the first floor, above the smoke barrier doors next to the Great Room, there was an unsealed MC wire penetration. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant at 3:15 p.m. on the same day. The unsealed penetration in the rated smoke wall compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating as per NFPA 101 standards.
Plan Of Correction
1. Unsealed wire penetration was corrected and sealed using an UL approved stop gap penetration system for sealing the penetration. 2. 3/13/25 3. The maintenance director will be educated on unsealed penetrations. 4. Audits will be conducted monthly random checks behind ceiling tiles to ensure any unsealed penetrations are not found. If found, they will be corrected at that time.
Smoke Barrier Doors Blocked by Equipment
Penalty
Summary
The facility failed to ensure that smoke barrier doors were properly inspected and maintained to fully close and resist the passage of smoke in one of two wings. During an observation on March 12, 2025, at 2:50 p.m., it was noted that the smoke barrier doors next to room 508 on the first floor did not close tightly. This issue was caused by the doors being blocked by a berri lift, which prevented them from closing smoke tight. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that the doors were indeed blocked, inhibiting their ability to close properly. This deficiency was identified as a failure to comply with the requirements for smoke barrier doors as outlined in NFPA 101, which mandates that such doors must be self-closing or automatic-closing and able to resist the passage of smoke.
Plan Of Correction
1. The Bari lift was removed; doors close properly. 2. 3/13/25 3. Staff educated on not blocking doors. 4. Director of maintenance will conduct a round audit to ensure doors are clear once a week for 2 weeks.
HVAC Exhaust Diffuser Maintenance Deficiency
Penalty
Summary
The facility failed to maintain HVAC exhaust diffusers on one of its two levels. During an observation on the first floor, inside the soiled utility room of the 500 wing, an HVAC exhaust/intake diffuser was found dislodged from the ceiling. It was powered and resting on top of wall-mounted cabinets, positioned on the intake side. This issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
1. HVAC exhaust/intake diffuser placed back in the ceiling. 2. 4/28/25 3. Maintenance staff educated on ensuring exhaust system is back in place. 4. Director of maintenance will audit soiled utility rooms once a month.
Electrical Panel Accessibility and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that electrical panels were protected and accessible, as required by NFPA standards. During an observation in the basement at the outdoor dock area, a large central supply order was found stored, leaning on, and blocking the main electrical high voltage switch gear handles. Additionally, in the kitchen, an exposed three-wire electrical conduit was observed hanging above the dishwasher drying rack discharge, with wire nuts and electrical tape on the wires, not properly terminated into an appliance. Furthermore, janitorial equipment was found obstructing access to electrical panels in the mechanical room on the first floor, across from room 330. These deficiencies were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
Order removed from the front of the main electrical panel. A. Wires capped off and placed away from the dishwasher drying rack discharge on the same day. Housekeeping director educated on not having janitorial equipment in front of electrical panels. The Director of maintenance will conduct rounds to ensure nothing is covering the panels once a month.
Unauthorized Use of Power Strips and Extension Cords
Penalty
Summary
The facility failed to maintain proper electrical wiring and equipment usage, leading to unauthorized use of power strips and extension cords. Observations on March 12, 2025, revealed that in the basement, a dehumidifier was plugged into an extension cord powered from a ceiling receptacle. Additionally, in the Admissions Office, a microwave, mini-fridge, and toaster were plugged into a power strip. These actions were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, indicating non-compliance with the required standards for electrical equipment usage.
Plan Of Correction
Extension cords removed from both locations. 3/13/25 Staff educated on extension cords in facility. The Director of maintenance will conduct random facility audits.
Unsecured Propane Tank Found in Facility
Penalty
Summary
The facility failed to ensure the security of portable gas cylinders, specifically a propane tank, which was found unsecured in the basement at the outdoor dock area. This propane tank was stored in front of the main electrical high voltage switch gear, posing a potential safety hazard. The observation was made on March 12, 2025, at 12:35 p.m. During the exit interview conducted on the same day at 3:15 p.m., the Administrator, Director of Maintenance, and Assistant confirmed that the portable tank was not adequately protected. This deficiency affected one of the two levels within the facility, indicating a lapse in the facility's adherence to the NFPA 101 standards for gas equipment storage and security.
Plan Of Correction
Propane tank removed from being stored in front of main electrical panel. 4/28/25 Staff educated on not storing propane tanks in front of electrical panels. The director of maintenance will conduct random facility audits.
Failure to Maintain Smoking Area Cleanliness
Penalty
Summary
The facility failed to adhere to smoking regulations as observed on March 12, 2025. During an inspection at 9:00 a.m., it was noted that there was an accumulation of cigarette butts in the mulch beds, outside resident room windows, along the building's side driveway, and outside the designated smoking area. This indicates a lack of proper disposal and management of smoking materials in the designated smoking area. The issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant at 3:15 p.m. on the same day.
Plan Of Correction
1. Cigarette butts were cleaned out of the mulch. 2. 4/28/25 3. Staff were educated on cigarette smoking area. There are appropriate ashtrays and appropriate metal self-closing device to empty the ashtrays. 4. Director of maintenance will audit grounds 1x a week for 2 weeks.
Deficiency in Emergency Preparedness Training Program
Penalty
Summary
The facility was found deficient in maintaining an emergency preparedness training program as required by regulations. During a document review on March 12, 2025, it was discovered that the facility failed to provide documentation of an emergency preparedness training program that is based on the Emergency Preparedness Plan. This program should include initial and annual training for all staff members, but the necessary documentation was not available. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed the facility's failure to develop an Emergency Preparedness Plan that includes a training program. This lack of documentation and development of a comprehensive training program indicates a significant oversight in the facility's emergency preparedness efforts.
Plan Of Correction
Facility conducted an annual in-service for staff on the emergency preparedness plan and training program. 4/28/25 Staff will be educated annually to remain in compliance. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date.
Failure to Document Emergency Preparedness Training
Penalty
Summary
The facility was found to be deficient in maintaining documentation of initial and annual Emergency Preparedness training for staff and individuals providing services, including volunteers. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility failed to provide maintained annual documentation of Emergency Preparedness training for staff members, which is necessary to demonstrate their knowledge of emergency procedures. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day. The interview corroborated the findings that the facility did not have the required annual records of employee training in emergency preparedness. This lack of documentation indicates a failure to comply with the regulatory requirement to provide and document such training annually. The report does not mention any specific incidents involving patients or any immediate consequences resulting from this deficiency. The focus is solely on the facility's failure to maintain proper records of emergency preparedness training, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
1. Facility conducted an annual in-service for staff on the emergency preparedness plan. 2. 4/28/25 3. Staff will be educated annually to remain in compliance. 4. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date 8/25. Director will keep record in maintenance binder.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale exercise and an additional exercise to test the emergency preparedness plan. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility did not perform these exercises within the previous 12 months, which is a requirement under the emergency preparedness regulations. The deficiency affects the entire facility, as the exercises are crucial for ensuring that the emergency preparedness plan is effective and that staff are adequately trained to respond to emergencies. The lack of documentation confirming the completion of these exercises indicates a significant oversight in maintaining compliance with regulatory requirements. During the exit interview on March 12, 2025, the Administrator, Director of Maintenance, and an assistant confirmed the absence of documentation for the required exercises. This confirmation further substantiates the finding that the facility did not meet the necessary standards for emergency preparedness testing.
Plan Of Correction
1. Facility conducted a tabletop exercise on an active shooter event. 2. 4/28/25. 3. The Director of maintenance will create a schedule to have tabletop exercises annually. 4. Director of maintenance will complete random facility audits.
Egress Clearance Deficiencies
Penalty
Summary
The facility failed to maintain the minimum required clearances along the means of egress, affecting both levels of the building. During an observation, it was noted that the Northeast Stair Tower had a width of 33 inches, which is below the required width of 36 inches. Additionally, the Basement Level was found to have inadequate headroom clearance along the exit access corridor, with a height of approximately six feet, six inches, which is less than the required six feet, eight inches. These deficiencies were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Smoke Compartment Size Exceeds NFPA 101 Standards
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the subdivision of building spaces into smoke compartments. Specifically, the smoke compartments on the 400 wing (zone two) and the First Floor (zone three), encompassing Rooms 101-111 and 101-302, exceeded the maximum allowable size of 22,500 square feet. This deficiency was identified through a combination of observation, document review, and interviews conducted on March 12, 2025. During the exit interview, the Administrator, Director of Maintenance, and Assistant confirmed that the smoke compartments were larger than permitted by the regulations.
Emergency Generator Lacks Battery Back-Up Lighting
Penalty
Summary
The facility failed to maintain the required emergency generator components, which affected the entire facility. During an observation on March 12, 2025, at 12:45 p.m., it was noted that the emergency generator set, located in the electrical room in the basement, did not have battery back-up emergency lighting. This deficiency was identified through direct observation and was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant later that day. The absence of battery back-up emergency lighting in the generator set location is a critical oversight in maintaining the essential electrical systems as required by NFPA standards. The lack of this back-up lighting could potentially compromise the facility's ability to respond effectively in an emergency situation where power is lost, although the report does not explicitly state the consequences. The deficiency was confirmed through both observation and interview, indicating a lapse in the facility's adherence to established maintenance protocols for emergency power systems.
Plan Of Correction
Director of maintenance working on finding an electrician to install a battery back-up light for the emergency generator. 4/28/25 Once electrician is scheduled, director of maintenance will continue to audit the emergency generator weekly.
Lack of Documentation for PRN Psychotropic Medications
Penalty
Summary
The facility failed to document the rationale for the continued use of PRN anti-anxiety medications for three residents who were on psychotropic medications. Resident 47, diagnosed with anxiety, major depressive disorder, and end-stage renal disease, was administered Ativan PRN multiple times from January to March 2025 without documentation from the physician to extend the PRN order beyond 14 days. Similarly, Resident 106, with peripheral vascular disease, diabetes mellitus, and bipolar disorder, received Ativan PRN several times from January to February 2025, again without the necessary documentation for extending the PRN order. Resident 128, who had major depressive disorder, metabolic encephalopathy, Parkinson's disease, type 2 diabetes mellitus, anxiety, and unspecified dementia, was administered Ativan gel PRN numerous times from November 2024 to March 2025. Additionally, this resident received lorazepam PRN frequently from January to March 2025. In both cases, there was no documentation from the physician to justify extending the PRN orders beyond the initial 14 days. The facility's administrator confirmed the lack of documentation to support the rationale for extending these PRN psychotropic medications.
Plan Of Correction
1. Orders for resident 47, resident 106, and resident 128 were reviewed by the physician and end dates for PRN psychotropic medications were applied on 3/6/25. 2. DON/ADON will audit all PRN psychotropic medication orders to ensure end dates are in place. 3. DON or Designee will educate nurses on PRN end dates and reassessment after 14 days. Education will be given to provider to document rationale for any continuation for PRN psychotropic medication. 4. DON or designee will complete audit on PRN psychotropic medication orders weekly x3, and monthly x2. Results will be presented at QAPI.
Infection Control Deficiencies in PPE and Precautionary Measures
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in deficiencies in the implementation of Transmission-Based Precautions (TBPs) and Enhanced Barrier Precautions (EBPs) for several residents. Specifically, Resident 12, who tested positive for influenza A, was not properly managed under Droplet Precautions. Observations revealed that an environmental services worker and a registered nurse entered the resident's room without the required personal protective equipment (PPE), such as gowns and eye protection, and the nurse was unaware of the resident's precautionary status due to the absence of appropriate signage. Additionally, the facility did not implement EBPs for residents at risk of Multi-Drug Resistant Organisms (MDROs). Resident 19, with a history of open wounds, and Resident 49, with a suprapubic catheter, were not managed with the necessary protective gowns, and there was no signage indicating their precautionary status. Similar lapses were observed for Resident 86, who had a permanent catheter, and Resident 131, with an indwelling catheter, as staff entered their rooms without the required protective gowns. The Director of Nursing confirmed that the facility's policies for Droplet and Enhanced Barrier Precautions were not being followed by the staff. This lack of adherence to infection control protocols was observed across two of the three nursing units, affecting five of the 28 sampled residents, and highlights a systemic issue in the facility's infection control practices.
Plan Of Correction
1. DON/Admin rounded the facility to ensure all staff were wearing proper PPE. Signage applied to identified rooms. 2. Educated staff on donning and doffing PPE. 3. Full house re-education will be provided to all staff on the proper usage of PPE, infection control, donning and doffing PPE. 4. DON or designee will complete audits weekly x2 to ensure appropriate signs are displayed outside of resident rooms and staff are wearing proper PPE while providing care. Results will be reviewed at QAPI.
Deficiencies in Safe and Homelike Environment
Penalty
Summary
Valley Manor Rehabilitation and Healthcare Center was found to be non-compliant with the requirements for providing a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. During the survey conducted on March 4, 2024, several deficiencies were observed across multiple rooms in the facility's Central nursing unit. These included broken fixtures, such as a doorknob in room 103 and a closet door in room 209, as well as missing amenities like paper towels in room 103. Additionally, numerous rooms had walls that were heavily marred with chipped paint, including rooms 105, 106, 107, 111, 113, 201, 202, 209, 211, 213, and 215. Other issues included window curtains being off the rod in rooms 106, 202, and 211, and privacy curtains stained in room 211. Structural problems were also noted, such as a large hole along the baseboard in room 201, broken and missing tiles in rooms 213 and 215, and closet doors peeling and separating in rooms 107, 209, and 213. These observations indicate a failure to maintain the facility in a manner that ensures a safe and comfortable environment for residents, as required by federal and state regulations.
Plan Of Correction
1. Rooms were addressed during the visit. 2. The maintenance Director and Housekeeping Director will conduct environmental rounds together to ensure room issues are rectified and addressed. 3. The maintenance director will create a painting schedule for each room and coordinate with nursing and housekeeping until completion. Housekeeping will provide deep clean/target room schedules. Staff will be educated on utilizing maintenance work order forms to report any issues identified. Maintenance director will address work order forms as received. 4. Administrator or designee will conduct weekly audits on room rounds to ensure progress is being made in rooms and issues corrected. Data will be reviewed at QAPI.
Failure to Provide Adequate Grooming and Hygiene Services
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for two residents who required extensive assistance with activities of daily living (ADLs). Resident 49, diagnosed with dementia, diabetes mellitus, and polyneuropathy, was observed with long and dirty fingernails on two consecutive days, despite the care plan indicating that staff should trim nails on shower days. The resident was able to communicate his needs and expressed that his fingernails needed to be cut. Similarly, Resident 63, who had a history of stroke, chronic pain, and depression, was also observed with long and dirty fingernails and an unshaved beard. The care plan for this resident included interventions for nail trimming and facial hair grooming on shower days. The resident communicated his desire for his fingernails to be cut and his beard shaved. The Director of Nursing confirmed that the residents' grooming needs should have been addressed during bathing and as needed.
Plan Of Correction
1. Resident 49 fingernails were cut during survey. Resident 63 fingernails were cut, and his beard was trimmed on evening shift on 3/5/25. 2. DON/ADON did a house-wide audit on current residents listed as dependent with ADL. 3. Educated Unit managers on ADL care policy, as well as CNA's and LPNs. 4. DON or designee will conduct weekly audits during rounds to sample five dependent residents on each unit to ensure they receive nail care and facial hair grooming on shower days. Audits will be conducted weeklyx3 for two weeks, and then weeklyx4. Results will be reviewed at QAPI.
Failure to Implement Physician's Orders for Wound Care
Penalty
Summary
The facility failed to implement physician's orders for a resident with multiple medical conditions, including atrial fibrillation, chronic obstructive pulmonary disease, and diabetes mellitus. The resident, who also had cognitive impairment, was found to have multiple bilateral lower extremity wounds from frostbite. A physician's order required daily wound care, including soaking the feet, applying betadine, and using specific dressings. However, the Treatment Administration Records indicated that the wound care was not performed as ordered on several occasions. This was confirmed by the Nursing Home Administrator during an interview.
Plan Of Correction
1. Wound care was completed for resident 249 on 3/4/25. Nurses on assignment were re-educated. Wound doctor assessed residents wound on 3/5/25 and there were no signs of an infection, or any harm caused to the resident. 2. DON/ADON conducted an audit on all wounds in-house to ensure they were completed and orders followed on 3/4/25. 3. IDT reviewed and updated the facility wound care policy. DON/designee provided education on the updated wound policy to licensed nursing staff. 4. DON or Designee will complete weekly wound audits to ensure wound care is being provided as ordered. Audits will be conducted weekly x2, and monthly x1. Results will be reviewed at QAPI.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified in the regulation effective July 1, 2024. During a review of nursing schedules over a 21-day period from February 13, 2025, to March 5, 2025, it was found that the facility did not meet the required staffing levels on three occasions. Specifically, on February 16 and February 23, 2025, the day shift (7:00 a.m. to 3:00 p.m.) did not have the minimum one NA per ten residents. Additionally, on March 3, 2025, the evening shift (3:00 p.m. to 11:00 p.m.) failed to maintain the required one NA per eleven residents. These deficiencies indicate a failure to adhere to the staffing regulations set forth for ensuring adequate care for residents.
Plan Of Correction
1. The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff callouts, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. 2. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. 3. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation. 4. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Non-compliance with NA to Resident Ratio
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratio on one of the seven days reviewed. Specifically, on January 11, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not maintain the minimum ratio of one NA per ten residents. This deficiency was identified through a review of nursing schedules covering the period from January 10 through January 16, 2025. The Director of Nursing confirmed during an interview on January 17, 2025, that the facility did not meet the required staffing ratios on the specified day.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules for the week of January 10 through January 16, 2025. Specifically, on January 11, 2025, the facility provided only 3.17 hours of care per resident, falling short of the mandated minimum. This shortfall was confirmed by the Director of Nursing during an interview conducted on January 17, 2025.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor state staffing ppd compliance. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state staffing ppd regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit PPD weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to their preferences, as evidenced by the experiences of two residents. Resident 2, who has a diagnosis of anxiety and hypertension, was served a lunch that included buttered carrots, despite her meal tray ticket indicating a dislike for carrots. The resident confirmed that she was not offered a substitute and often received items she did not prefer. This incident was observed on January 3, 2025, and the resident was alert and oriented at the time. Similarly, Resident 3, who has heart failure and diabetes, was served lemonade with his meal, even though his meal ticket specified that he disliked lemonade. The resident, who was also alert and oriented, confirmed that he frequently received lemonade despite his stated preference. The dietary department was expected to follow the residents' preferences as identified on the meal tickets, but this was not adhered to in these cases.
Plan Of Correction
Facility provided re-education to the dietary staff on following food preferences listed for residents. NHA/Food Service Director will review job functions of the dietary tray line with the tray line staff. Re-education will include having last person on the tray line double checking items on tray against items listed on preferences. NHA/Designee will conduct audits 3 times a week for 2 weeks, then weekly for 4 weeks to ensure residents are being served items according to their listed preferences. All results will be reported to the QAPI Committee.
Failure to Post Menus Two Weeks in Advance
Penalty
Summary
The facility failed to comply with the regulation requiring menus to be planned and posted at least two weeks in advance. During a tour of the facility, it was observed that the menus posted on the nursing units only included lunch and dinner meals for January 3 and 4, 2025, rather than the required two-week advance posting. In an interview, the Registered Dietician admitted that menus were neither given to residents nor posted two weeks in advance. The Nursing Home Administrator confirmed this deficiency, acknowledging that the facility did not meet the regulatory requirement for menu posting and distribution.
Plan Of Correction
Dietary Director was posting menus in a common area daily; the NHA re-educated the director on posting menus two weeks in advance. Dietary Director will distribute two weeks' worth of menus at least weekly to residents and have them posted as well. NHA/Designee will conduct audits to ensure two weeks' worth of menus are posted and available for residents. Audit will be conducted weekly at 4 weeks, then monthly x 2. All results will be reported to the QAPI Committee.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified in the regulation effective July 1, 2024. During a review of nursing time schedules from December 2 through 22, 2024, it was found that the facility did not meet the required staffing levels on several occasions. Specifically, the facility did not maintain the minimum ratio of one NA per 10 residents during the day shift on December 8, 9, 14, 15, 20, and 21, 2024. Additionally, the facility failed to meet the minimum ratio of one NA per 15 residents during the night shift on December 8, 9, 10, 14, and 15, 2024. These deficiencies were identified over a period of seven out of the 21 days reviewed.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. The NHA or designee will educate the DON/ADON and Nursing Supervisors on state ratio staffing regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly for 4 weeks, bi-weekly for 2 weeks, and monthly for 1 month. The results will be reviewed at the QAPI meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of nursing time schedules from December 2 through 22, 2024, revealed that on six specific days, the facility did not meet this requirement. On December 8, 9, 10, 13, 14, and 15, 2024, the care hours per resident were 2.70, 2.92, 2.93, 3.07, 2.97, and 2.81, respectively. This deficiency was identified based on the analysis of the nursing time schedules, indicating a shortfall in the required nursing care hours for the residents on these days.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor state staffing ppd compliance. The NHA or designee will educate DON/ADON and Nursing Supervisors on state staffing ppd regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X2 and monthly X1. The results will be reviewed at the QAPI meeting.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision to prevent an elopement incident involving a resident at high risk for elopement. The resident, who had been identified as cognitively impaired and at risk for elopement since admission, was last seen wandering the facility at approximately 5:00 a.m. on the day of the incident. The resident managed to push open the front door of the facility and leave unattended, despite the presence of an alarm system. Staff failed to respond to the alarm, allowing the resident to leave the premises. The resident was found over three hours later, approximately 5.5 miles away from the facility, having crossed a four-lane highway and walked on unlit rural roads. The incident was identified as an Immediate Jeopardy situation due to the lack of adequate supervision and monitoring of the resident's whereabouts, which was a direct violation of the facility's elopement policy. The deficiency was noted as past non-compliance, and the facility was required to implement a corrective action plan.
Pest Control Deficiency in North Unit
Penalty
Summary
The facility failed to maintain an effective pest control program in one of its three nursing units, specifically the North unit. On July 25, 2024, at 10:42 a.m., flies were observed in the hallway and in rooms 304, 308, 405, and 407. A subsequent observation on the same day at 11:38 a.m. confirmed the presence of flies in the hallway and in rooms 303, 304, 308, 405, and 407. During an interview conducted on July 25, 2024, at 12:40 p.m., the Administrator confirmed the presence of flies on the North unit, indicating a lapse in the facility's pest control measures.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse and did not report the incidents to the State Licensing Agency. Resident 1, who had a history of behavioral disturbances including yelling, screaming, cursing, and pushing others, was involved in two incidents of physical abuse. On March 8, 2024, Resident 1 was documented pushing Resident 6 against a soda machine and attempting to hit them. This incident was not reported by the shift supervisor or investigated by the Administrator, Director of Nursing, or Risk Manager until March 19, 2024. On March 14, 2024, Resident 1 was involved in another incident where he pushed Resident 2, causing them to fall to the ground after a verbal altercation. This incident was also not reported to the State Licensing Agency. The facility's policy on abuse prevention and reporting was not followed, as confirmed by the Administrator and Director of Nursing during an interview on March 19, 2024. The facility's failure to report and investigate these incidents in a timely manner constitutes a deficiency in ensuring resident safety and compliance with state regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 366 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Coopersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Weston Rehabilitation & Nursing Center | 3.6 mi | — | 0 | 0 |
| Phoebe Richland Hcc | 5 mi | ★★★★★ | 6 | 0 |
| Lifequest Nursing Center | 5.6 mi | ★★★★★ | 5 | 0 |
| Belle Terrace | 6.2 mi | ★★★★★ | 15 | 0 |
| Good Shepherd Home Raker Center | 6.4 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.