Valley View Health Care Center, Inc

F-F689: failure to prevent a resident from eloping a secured locked facility.

Findings include:

I. Facility policy and procedure

The Facility Assessment policy, dated October 2018, was provided by the nursing home administrator (NHA)

on 2/26/25 at 5:26 p.m. It read in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment.

The facility assessment includes a detailed review of the resident population.

The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population.

The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation.

II. Record review

The facility assessment was last reviewed on 2/14/25 by the NHA, the director of nursing (DON), the medical director and the governing body and other members of the leadership team.

The facility assessment failed to document:

-The supplies, equipment and care needed when operating a totally secured locked facility;

-The care required by the resident population, using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments; and,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 065347 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065347 B. Wing 02/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Health Care Center, Inc 2120 N 10th St Canon City, CO 81212

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 -Include staff training/education necessary to provide the level and types of support and care needed for the resident population needing to reside in a secured locked environment. Level of Harm - Minimal harm or potential for actual harm III. Staff interviews

Residents Affected - Many The NHA was interviewed on 2/26/25 at 5:33 p.m. The NHA said the facility assessment was recently updated but she did not remember specifically what was written about the needs of the resident in relation to needing to live in a totally secure facility. The NHA said she would meet with the leadership team and discuss the resident needs and update the facility assessment to reflect more information on providing the resident population a safe and secure environment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 065347 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065347 B. Wing 02/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Health Care Center, Inc 2120 N 10th St Canon City, CO 81212

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0843 Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Level of Harm - Minimal harm or potential for actual harm 31820

Residents Affected - Many Based on record review and interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate.

Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital.

Findings include:

I. Record review

A request was made to the nursing home administrator (NHA) on 2/26/25 at 2:10 p.m., for the facility's hospital transfer agreement.

-The facility was unable to provide a written agreement for the one area hospital.

II. Staff interview

The NHA was interviewed on 2/27/25 at 2:53 p.m. The NHA said the facility could not locate a hospital transfer agreement. The NHA said she reached out to the local hospital and would get a transfer agreement completed since she could not locate a current agreement. She said it was important to have a hospital transfer agreement in case the facility needed to send a resident out.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 065347