Valley Manor Infection Control Violation - MO
EXCELSIOR SPRINGS, MO - Federal inspectors documented serious infection control deficiencies at Valley Manor and Rehabilitation Center during a July 2024 inspection, finding that staff failed to implement proper protective measures for high-risk residents and lacked adequate antibiotic monitoring programs.
Critical Breakdown in Enhanced Barrier Precautions
The most significant violation involved the facility's failure to implement Enhanced Barrier Precautions (EBP) for residents who required these specialized infection control measures. These precautions are designed to prevent the transmission of multidrug-resistant organisms (MDROs) and require staff to wear gowns and gloves during high-contact care activities.
Three residents were identified as requiring enhanced precautions but receiving inadequate protection. Resident #34, who had severe dementia and required total care including feeding through a gastric tube, should have been under enhanced precautions due to the indwelling medical device. Similarly, Resident #63, who had a urinary catheter and required total care, needed these additional protections. Most concerning was Resident #23, who had a documented history of multidrug-resistant organisms and infected surgical hardware from a hip repair.
Despite clear medical indications for enhanced precautions, inspectors found no identification signs outside these residents' rooms, no care plans addressing infection prevention protocols, and no resources to alert staff about required protective equipment. The failure to properly identify and protect these vulnerable residents created significant risks for disease transmission throughout the facility.
Staff Knowledge Gaps Pose Safety Risks
Interviews with nursing assistants revealed alarming gaps in basic infection control knowledge. When asked about enhanced barrier precautions, one nursing assistant stated they "did not know what enhanced barrier precautions was" and was "not sure if resident #34, #63 should be on isolation." Another staff member "did not believe that resident #34 or #63 should be on isolation, and was not told that in report."
These knowledge deficits are particularly concerning given the medical conditions of the affected residents. Gastric feeding tubes and urinary catheters create direct pathways for bacteria to enter the body, making proper infection control protocols essential. When staff are unaware of these risks or proper procedures, residents face increased chances of developing serious infections that could lead to sepsis, prolonged hospital stays, or death.
The medical significance of these violations extends beyond the immediate residents involved. MDROs can spread rapidly through healthcare facilities when proper precautions are not followed. These antibiotic-resistant bacteria are particularly dangerous because they are difficult to treat and can cause severe infections in vulnerable populations like nursing home residents.
Hand Hygiene Failures During Critical Care
Inspectors documented a separate but equally serious violation involving improper hand hygiene during personal care. During observation of care for Resident #58, who had diabetes, heart conditions, and a urinary catheter, staff failed to follow basic hand washing protocols multiple times during a single care episode.
The nursing assistant was observed removing gloves after cleaning fecal material without washing hands before putting on new gloves, then repeating this error again during the same care session. This creates a direct pathway for bacterial transmission from contaminated areas to clean areas of the resident's body, particularly dangerous for someone with a urinary catheter.
Hand hygiene represents the most fundamental infection control measure in healthcare settings. The Centers for Disease Control and Prevention identifies proper hand washing as the single most effective way to prevent healthcare-associated infections. When staff skip this critical step, especially during intimate care involving bodily fluids, they significantly increase the risk of introducing harmful bacteria into sterile body systems.
For residents with indwelling medical devices like catheters, improper hand hygiene can lead to catheter-associated urinary tract infections (CAUTIs), which can progress to kidney infections or bloodstream infections. These complications can be life-threatening for elderly residents with multiple chronic conditions.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
VALLEY MANOR AND REHABILITATION CENTER in EXCELSIOR SPRINGS, MO was cited for violations during a health inspection on July 10, 2024.
Three residents were identified as requiring enhanced precautions but receiving inadequate protection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.