The problems centered on how nursing staff handled incidents involving two residents in September and October. When one resident was found crawling on the floor, the nurse documented the incident but failed to notify the attending physician or complete mandatory fall assessments.
Resident #4's case illustrated the documentation failures. On September 5, Licensed Vocational Nurse E responded after another resident reported seeing Resident #4 crawling on the floor. LVN E documented contacting the responsible party but made no record of notifying the doctor or receiving medical orders. She also skipped the required fall risk assessment, skin assessment, and neurological checks.
The Assistant Director of Nursing later told inspectors that LVN E should have treated the incident as a fall since she didn't witness what happened. "Another resident may or may not have had the cognitive ability to say what happened," the ADON explained. Regardless of the circumstances, proper protocols required full documentation and physician notification.
A second case involved Resident #13, who experienced aggressive behavior on October 10 followed by an actual fall three days later. Licensed Vocational Nurse F failed to complete a change of condition form after the behavioral incident, despite facility policy requiring documentation whenever residents showed changes in condition.
When Resident #13 fell on October 13, LVN D filled out a change of condition form but used a blood sugar reading from two years earlier instead of current vital signs. The ADON told inspectors this was "not appropriate for a change of condition assessment." Current blood pressure, pulse, respiratory rate, oxygen saturation and temperature should have been documented.
The Director of Nursing revealed that LVN F had received specific instructions about completing the required forms. "She told him when to do the change of condition form for Resident #13 and the other resident when he called, but he did not do them," the DON said during her interview with inspectors.
The DON had to intervene multiple times to complete missing documentation. She conducted the change of condition form for Resident #13 over the phone with LVN F after discovering it hadn't been done. She also performed a skin assessment on Monday morning October 13 because LVN F had failed to complete it after the October 10 incident.
LVN F stopped working at the facility after October 10.
The documentation failures violated the facility's own policies dating back to 2008. Valley Grande Manor's Charting and Documentation Policy specifically requires staff to document "all incidents, accidents, or changes in the resident's condition" and mandates notification of "family, physician or other staff, if indicated."
All three nurses involved had received training on falls, incident response, identifying changes of condition, and completing risk management forms. The required assessments include pain evaluation, fall risk assessment, skin assessment, neurological checks, and change of condition documentation.
The DON emphasized the stakes of proper documentation during her interview. "If staff failed to document, residents could go without the care needed," she told inspectors.
The inspection found that nursing staff consistently skipped required steps in the incident response process. When residents experienced falls or changes in condition, nurses failed to notify physicians, document current vital signs, or complete mandatory risk assessments designed to prevent further injuries.
Federal regulations require nursing homes to immediately assess residents after incidents and notify attending physicians of any changes in condition. The documentation serves as a critical communication tool between nursing staff and doctors who may not be present at the facility when incidents occur.
Valley Grande Manor's failures left residents vulnerable to additional harm. Without proper physician notification, doctors couldn't provide updated orders for care. Without current vital signs and assessments, staff lacked baseline information to detect complications or deterioration.
The facility's own policies recognized these risks, requiring detailed documentation of all procedures and treatments with "care-specific details." Staff were specifically trained on these requirements but repeatedly failed to follow them when residents needed care most.
The inspection documented how multiple licensed nurses at different levels skipped basic safety protocols, from the initial response to incidents through the completion of required paperwork. Each failure represented a missed opportunity to ensure residents received appropriate medical attention after potentially serious events.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Grande Manor from 2025-11-21 including all violations, facility responses, and corrective action plans.