Valley View Manor Hcc

During an interview on 11/18/25 at 12:24 p.m., hospice registered nurse (H-RN) stated that as a hospice nurse she is a contracted staff that provided extra support to residents in the facility while under hospice care. H-RN performed a routine visit for R5 on 11/13/25 when R5 informed her she had been sitting in feces for a long time and staff would not assist her with changing her brief or clean her up, and that she had not received a shower since she was admitted to the nursing home. H-RN also observed a large open blister on R5's right lower leg with a large purple discoloration on the back of her leg, of which to her appeared to be a large bruise. H-RN stated she had asked the interim assistant director of nursing (I-ADON) if he was aware of how R5 obtained the bruise and blister, however, was told he did not know anything about it. H-RN stated normally she would report this type of concerns of neglect and injury of unknow origin to the director of nursing (DON) and/or the administrator, however, the DON was busy with another resident, so she did not report this information to her or the administrator.

During an interview on 11/19/25 at 2:44p.m., the administrator stated hospice agency staff were considered contracted staff and need to follow the same policies and procedures for reporting as the staff in the facility.

If any staff, including contracted staff became aware of an allegation of neglect they would report this immediately the DON or the administrator, however, had not had any reports of allegation of neglect made by any contracted staff.

Review of the facility Hospice Services Agreement dated 2/24, identified that hospice should report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the facility administrator within 24 hours of the hospice becoming aware of the alleged violation.

During an interview on 11/21/25 at 4:20 p.m., clinical director of hospice (CD-H) stated she was unaware if the hospice agency would follow the facility's reporting policy and was unaware if they had received the facility reporting policy. CD-H was unaware the hospice services agreement dated 2/24, identified that if hospice received an allegation this would need to be reported immediately to the facility administrator.

Review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy undated, identified that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator, director of nursing and the other officials according to state law.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record.

The explanation should include what steps were taken to include the resident or representative in the process.5.

The comprehensive, person-centered care plan:1. includes measurable objectives and timeframes.2. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:1. services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.2. any specialized services to be provided because of PASARR recommendations; and3. which professional services are responsible for each element of care.3. includes the resident's stated goals upon admission and desired outcomes.4. builds on the resident's strengths; and5. reflects currently recognized standards of practice for problem areas and conditions. 6.

Services provided for or arranged by the facility and outlined in the comprehensive care plan are:1. provided by qualified persons.2. culturally competent; and3. trauma informed.7.

Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.8.

When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.9.

Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.10.

The interdisciplinary team reviews and updates the care plan:1. when there has been a significant change in the resident's condition.2. when the desired outcome is not met.3. when the resident has been readmitted to the facility from a hospital stay; and4. at least quarterly, in conjunction with the required quarterly MDS assessment.11.

The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments.

Such refusals are documented in the resident's clinical record in accordance with established policies.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 11/12/25 at 3:56 p.m., interim director of nursing (I-ADON) stated R2's care plan had not been revised to include any updated individualized fall prevention interventions nor R2's transfer changed to remove independent during transfers and had not had a wheelchair added to R2's care plan. I-ADON stated the DON does resident care plan revisions and not the nurses. R6's face sheet dated 11/19/25, identified diagnoses of hemiplegia (paralysis) affecting left side, diabetes mellitus (body does not make enough insulin), and heart failure (a condition where the heart does not pump enough blood to the body). R6's Annual [NAME] Data Set (MDS) dated [DATE], identified R6 was dependent for bed mobility/transfers, at risk for developing pressure ulcers, had no pressure ulcers, and was cognitively intact.R6's skin integrity focus care plan last revised on 4/29/25, identified R6 had a potential impairment to skin integrity related to bowel and bladder incontinence and impaired mobility.

Goal to maintain or develop clean and intact skin.

Interventions were as followed: may apply barrier cream after each incontinent episode; elevate heels off the bed; keep skin clean and dry, use lotion on dry skin, prefers to not be checked every two hours; pressure relieving/reducing cushion in wheelchair; standard pressure relieving/reducing mattress to protect skin while in bed.R6's nursing home rounding form dated 11/10/25, identified the nurse practitioner requested to check that R6's air mattress was working.

During an observation and interview on 11/18/25 at 10:21 a.m., R6 was lying in bed on top of a specialty mattress in place. R6 stated she had this type of mattress on for some time due to a sore on her bottom and because she spends a lot of time in bed. NA-F stated R6 had been on an air bed for some time because she had sore on her bottom.

During an interview on 11/18/25 at 10:57 a.m., director of nursing (DON) stated R6's care plan had not been revised to include the air mattress that was placed on her bed, and it should have been revised as soon as it was placed on her bed.

Review of the facility's Care Plan, Comprehensive Person-Centered Policy undated, identified the interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition.b. when the desired outcome is not met.c. when the resident has been readmitted to the facility from a hospital stay; andat least quarterly, in conjunction with the required quarterly MDS assessment

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 11/19/25 at 9:41 a.m., director of nursing (DON) stated R5 and R7's orders that were applied are not part of the standing orders of the facility and it would be standard of practice for a nurse to contact the physician to obtain an order prior to administering any treatment and her expectation would be for licensed staff to ensure this is done prior to initiating a treatment.

Review of the facility's Medication and Treatment Orders policy dated 6/30/24, identified orders for medications and treatments will be consistent with principles of safe and effective order writing.

Policy Interpretation and Implementation were as followed:1.

Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2.

Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 3.

Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart.

Such orders are reviewed by the Pharmacist on a monthly basis. 4.

All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. 5.

The signing of orders shall be by signature or a personal computer key.

Signature stamps may not be used. 6.

The staff and practitioner shall use only approved abbreviations and symbols when ordering and/or charting medications. 7.

Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date, and the time of the order. 8.

Verbal orders must be signed by the prescriber at their next visit. 9.

Orders for medications must include: a.

Name and strength of the drug.b.

Quantity, parameters, or specific duration of therapy.c.

Dosage and frequency of administration.d.

Route of administration; ande.

Reason or problem for which given. 10.

Only authorized personnel shall call in orders for prescribed medications to the pharmacy.

Review of the facility's Skin Care Policy and Procedure undated, identified new or ineffective skin problems will be referred to the appropriate health professional and skin treatments will be performed per medical doctor order.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

Assessment will be completed to identify risk for skin breakdown category,3.

Residents with identified skin conditions or problems are referred to the appropriate health professional i.e., NP, Wound Consultant or MD.4.

Resident care plan will detail specific skin care management instructions that include but not limited to: Skin care regimens (use of barrier/emollient creams); Repositioning frequency Aids (including pressure reducing mattresses, alternating surface mattress, wedges, cushions, and other equipment as required.

Moisture reduction Relevant lifting/transferring procedures.5.

Resident skin will be assessed weekly and/or as resident allows.6.

Skin treatments will be performed per MD order.7.

New or ineffectively managed skin problems will be referred to the appropriate health professional.8.

Staff receive education on skin care and wound management upon hire and as needed in response to identified knowledge deficits or incidents. or incidents.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

treatments will be performed per MD order.7.

New or ineffectively managed skin problems will be referred to the appropriate health professional.8.

Staff receive education on skin care and wound management upon hire and as needed in response to identified knowledge deficits or incidents

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

injury such as a fracture or bleeding, nursing staff will provide appropriate first aid.Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting or lying position and the staff will lift the resident via mechanical lift and will document relevant details.3.

Nursing staff will notify the resident's Attending Physician and family.

When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone.4.

Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record.5.

Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. A new fall and pain assessment should be completed.6. An incident report must be completed for resident falls.

The incident report form should be completed by the assigned staff nurse at the time via risk management incident portal.Defining Details of Falls:1.

After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred.Identifying Causes of a Fall or Fall Risk:1.

Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident.

They will refer to resident-specific evidence including medical history, known functional impairments, etc.2.

Staff will evaluate chains of events or circumstances preceding a recent fall, including:a.

Time of day of the fall.b.

Time of the last meal.c.

What the resident was doing.d.

Whether the resident was standing, walking, reaching, or transferring from one position to another.e.

Whether the resident was among other persons or a[TRUNCATED]

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 11/14/25 at 2:04 p.m., HIM stated R4 had a routine nursing home visit on 9/26/25, however, the note had not been removed from the outside medical system EHR to be placed into R4's chart until 11/14/25. HIM stated she was responsible for the uploading visit notes, that were received via fax.

The other notes from outside medical visits needed to be accessed prior to uploading them into the facility's EHR system which she did not have access to. HIM needed to have the director of nursing (DON) obtain the note for R1 and R4. HIM was unaware of the facility's process to ensure that the notes were placed timely in the resident's EHR.

During an interview on 11/19/25 at 4:10 p.m., vice president of clinical services (VP-CS) stated the facility has a system in the electronic health record that allows staff to enter the outside electronic health record and extract dictated notes and had shown the HIM a while ago on how to perform this task but had to demonstrate this task again today.

The staff would need to find the notes and download the notes and then place the note in the facility's EHR under the miscellaneous tab.

During an interview on 11/19/25 at 2:20 p.m., director of nursing (DON) stated she was unaware that R1 and R4's notes had not been placed in the facility's EHR in a timely manner. DON further stated R1 and R4's notes located in the outside medical record system belong to the outside medical system and are not a part of the facility's EHR, and her expectation would be that all resident's visit notes be placed in the EHR as soon and they are available and by not having R1 and R4's notes in the facility EHR could lead to something being missed and in the event of an emergency the resident's medical record would not be complete.

Requested the facility's policy on maintaining an accurate and complete medical record, however, did not receive.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

the following information from the hospice: (1) The most recent hospice plan of care specific to each resident. (2) Hospice election form. (3) Physician certification and recertification of the terminal illness specific to each resident. (4) Names and contact information for hospice personnel involved in hospice care of each resident. (5) Instructions on how to access the hospice's 24-hour on-call system. (6) Hospice medication information specific to each resident; and (7) Hospice physician and attending physician (if any) orders specific to each resident.j.

Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents.3.

Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Manor Hcc

200 East Ninth Avenue Lamberton, MN 56152

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 11/18/25 at 2:45 p.m., administrator stated that the QAA/QAPI committee meets monthly where the previous month's data is discussed and analyzed.

Administrator stated the facility had a sharp increase in falls from the month of October 2025 from the previous month of September 2025, however, the facility had not identified the increase in falls as a concern and therefore had not brought this concern to the quality committee to discuss and create and appropriate action plan to assist the facility to determine possible causes of the increase in resident falls.

Administrator stated this concern should be brought to the quality committee as soon as possible to develop a plan to correct this concern and not wait until the next month to address the problem.

Administrator stated with regards to the chemical restraints the facility had been cited May 2025 for concern for psychotropics being used as chemical restraints and not having a documented non-pharmacological intervention prior to administration.

The QAA/QAPI committee determined an action plan to begin doing audits of residents with prescribed as needed (PRN) psychotropics to ensure documentation was being completed by licensed staff of a non-pharmacological intervention prior to administering the PRN psychotropic.

The audits which began June 2025 and had not identified a concern for the months of 6/25. 7/25, however, the 8/25, 9/25 and 10/25 audits identified PRN psychotropics were being administered without a documented non-pharmacological intervention attempted prior being administered.

Administrator stated the QAPI committee had not discussed the identified concern for non-compliance and had not made any amendment to the facility's action plan and should have done this when the audits completed during 8/25, 9/25, and 10/25 identified non-compliance and if the QAPI committee had done this it may have prevented this non-compliance for re-occurring for an extended period.

Review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan policy identified the facility shall develop, implement, and maintain and ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems.

The objectives of the QAPI Plan are to:1.

Provide a means to identify and resolve present and potential negative outcomes related to resident care and services.2.

Reinforce and build upon effective systems and processes related to the delivery of quality care and services.3.

Provide structure and processes to correct identified quality and/or safety deficiencies.4.

Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome.5.

Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability.6.

Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility; and7.

Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program.

Facility ID: