Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madison Valley Manor during CMS and state inspections, most recent first.
Surveyors identified multiple instances of undated, unlabeled, and expired food items in storage areas and refrigerators, as well as improper storage of open food containers. Staff interviews confirmed inconsistent food inventory audits and lack of adherence to facility policy on food labeling. Additionally, a dusty oscillating fan was used to dry clean dishes without a set cleaning schedule, and a kitchen floor drain was found to be cracked, unsealed, and in disrepair for an extended period, with staff unable to secure timely repairs.
A kitchen freezer was not properly maintained, with the bottom shelves marked 'Do Not Use' due to issues causing freezer burn and a faulty door seal that failed to keep food frozen. Staff reported the freezer was scheduled for replacement but this was delayed, and food was sometimes discarded when staff forgot not to use the affected shelves.
The facility did not complete or document required assessments before using bed rails and a scoop mattress as restraints or assistive devices for three residents. In each case, documentation was missing or incomplete regarding whether the devices limited freedom of movement, if risks and benefits were discussed, and whether residents could remove the devices independently. Ongoing monitoring of these devices was also not consistently performed or documented.
A resident's representative was not notified after the resident sustained a fall with injury, was diagnosed with a UTI, and was started on antibiotics. Nursing notes documented the incidents and treatment changes, but there was no evidence that the representative was informed, contrary to facility policy.
The facility did not implement or make accessible a comprehensive grievance process, failing to post required information, provide accessible grievance forms, or offer a secure method for anonymous submissions. A resident was unaware of how to file a grievance or do so anonymously, and staff confirmed the lack of accessible forms and secure receptacle, contrary to facility policy.
Two residents were inaccurately assessed, with assistive devices such as a scoop mattress and bed rails incorrectly coded as restraints on their MDS assessments. Both residents were able to move and get out of bed independently, and staff confirmed the devices did not restrict their mobility, yet the documentation did not reflect this.
A resident with left-sided paralysis and limited hand mobility was found with bed rails in the up position and was unable to lower them independently. Staff and documentation failed to recognize and record the bed rails as a restraint, and the assessment did not address that the resident could not remove the rails or that they limited movement, contrary to facility policy.
The facility did not ensure competent nursing staff were available to provide timely medication administration and meet residents' needs. A resident and others reported issues with a travel nurse's attitude and care timeliness, and medication records showed that a resident received several medications hours after the scheduled time on multiple occasions, outside the facility's allowed window. The facility relied heavily on travel nurses, and some did not seek help when running late, resulting in late medication passes.
A hospice resident with advanced disease experienced inconsistent and delayed pain management, as staff often waited to administer stronger pain relief like morphine until after less effective medications were tried, despite ongoing pain. Documentation of pain assessments and follow-up was incomplete, and family members had to advocate for appropriate pain control, resulting in unnecessary discomfort.
The facility did not provide infection prevention and control training to temporary agency staff, as revealed through interviews and observations. A traveling CNA and two other traveling employees reported not receiving such training during their orientation. Observations showed improper hand hygiene practices, and there was no documentation of infection control training for these staff members.
A staff member failed to follow standard precautions during personal care of a resident by not sanitizing hands before donning gloves and not changing gloves between dirty and clean tasks. The staff member acknowledged the oversight, which was against the facility's policy requiring hand hygiene and glove changes to prevent cross-contamination.
The facility failed to ensure accurate MDS coding for diagnoses and restraints. One resident's dementia diagnosis was not updated in the MDS, and three other residents had discrepancies in the documentation of bed rails and alarms. Staff interviews confirmed the lack of a reliable process for updating diagnoses and inconsistencies in MDS coding.
The facility failed to update care plans for two residents, one regarding discontinued blood glucose monitoring and wheelchair use, and another regarding the removal of bed rails. Staff interviews and observations confirmed the discrepancies.
The facility failed to implement bed rails and update the care plan for a resident. Observations showed the absence of bed rails despite a physician's order and care plan indicating their use. Staff interviews revealed confusion about the bed rails' presence and lack of an order to discontinue their use.
Deficient Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices, as evidenced by multiple observations of undated, unlabeled, and expired food items in the dry storage area, walk-in refrigerator, and resident refrigerator. Items such as open bags of pasta, cereal, and chips, as well as expired Jello mix and undated containers of sauces and dairy products, were found. Staff interviews revealed that food inventory audits were intended to be performed monthly, but expired and improperly labeled items were still present. Facility policy required all foods to be covered, labeled, and dated, but this was not consistently followed. Additionally, the facility did not maintain a clean kitchen environment. An oscillating fan, used to blow air on racks of drying dishes, was observed to have visible gray dust on its spokes and back, with no set cleaning schedule in place. Staff acknowledged the need for cleaning but indicated it was only done when noticed and as time allowed. The fan continued to be used in this condition, posing a risk of dust contaminating clean dishes. The kitchen floor drain was also found to be in poor condition, with a damp towel covering it at times and visible cracks and openings around the drain. Staff interviews and documentation confirmed that the drain had been in disrepair for over a year, with a known crack in the pipe and ongoing difficulties in securing repairs. The area around the drain was unsealed, and odors were sometimes noticed, further indicating a lack of proper maintenance and sanitation in the kitchen environment.
Failure to Maintain Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that one of the kitchen freezers was adequately maintained and in safe operating condition. During observation, the bottom shelves of the kitchen entryway freezer were marked with cardboard signs stating 'Do Not Use,' yet food items were stored on all other shelves. Staff interviews revealed that the freezer was scheduled for replacement but this had been delayed due to planned kitchen renovations. Staff also reported that the bottom shelf caused freezer burn to food items, leading to food being discarded when staff forgot not to use those shelves. Additionally, there were issues with the freezer door seal, which failed to maintain the frozen state of foods placed on the bottom shelves. Review of the FDA Food Code confirmed that equipment components such as doors and seals should be kept intact and adjusted according to manufacturer specifications, and that corrective action should be taken if equipment fails to maintain proper storage conditions.
Failure to Assess and Document Use of Restraints and Assistive Devices
Penalty
Summary
The facility failed to perform and document complete resident assessments prior to the use of physical restraints or assistive devices that could be considered restraints for several residents. In one case, a resident with left-sided paralysis and limited hand mobility had upper bed rails in place, which he could not lower independently. Staff and the resident indicated the bed rails were used to prevent falls and assist with mobility, but documentation did not show whether the bed rails met the criteria for a restraint or if risks and benefits were discussed with the resident or representative. The assessments also failed to indicate if the resident could remove the bed rails independently, despite staff statements that the rails restricted his ability to get out of bed. Another resident was observed using a scoop mattress, which she stated did not restrict her movement and was used to assist with transfers and positioning due to poor core control. However, the facility did not complete or document an assessment prior to the initial use of the scoop mattress, nor did they provide ongoing monitoring of its use. The evaluation on file did not address whether the scoop mattress limited the resident's freedom of movement, and there was inconsistency in the documentation regarding whether it was considered a restraint. A third resident was observed with bed rails in the up position, which she stated helped prevent her from falling out of bed. Staff confirmed the bed rails were used for safety, and the resident was able to get out of bed independently. However, there was a lack of documented Assistive Device/Restraint Evaluations for an extended period, indicating a failure to perform ongoing monitoring of the use of bed rails as required. The facility's policy defined restraints based on the resident's ability to remove the device and its impact on freedom of movement, but the required assessments and documentation were incomplete or missing for the residents involved.
Failure to Notify Resident Representative of Fall, UTI, and Antibiotic Initiation
Penalty
Summary
The facility failed to notify a resident's representative regarding significant changes in the resident's condition and treatment. Specifically, the representative was not informed when the resident experienced an unwitnessed fall resulting in a skin tear and bruising on the right hand, wrist, and forearm. Nursing progress notes documented the fall and resulting injuries but did not indicate that the resident's representative was notified of the incident, as required by facility policy. Additionally, the facility did not notify the representative when the resident was diagnosed with a urinary tract infection (UTI) and subsequently started on antibiotics. Although staff believed the representative was aware that a urine specimen was being collected, there was no documentation or confirmation that the representative was informed of the UTI diagnosis or the initiation of antibiotic treatment. The facility's policy requires notification of family or representatives in the event of accidents resulting in injury or significant changes in treatment, which was not followed in these instances.
Failure to Provide Accessible Grievance Process and Information
Penalty
Summary
The facility failed to develop, implement, and operationalize a comprehensive grievance policy and procedure, as required. During a walk-through, it was observed that there was no documentation on how residents could file a grievance posted in common areas, and grievance forms were only available in a single location next to the nurse's station, which was partially obstructed by a chair. There was no posting of the name or contact information for the grievance official, and no secure receptacle or written information was available for residents to file grievances anonymously. A review of facility policy indicated that such information should be provided upon admission and posted on the resident bulletin board, but these requirements were not met. Interviews revealed that a resident was unaware of the location of grievance forms or the option to file grievances anonymously, expressing a desire for a receptacle to submit anonymous grievances. A staff member confirmed the limited and inaccessible placement of grievance forms and acknowledged the absence of a secure receptacle for anonymous submissions. The facility's own policy and resident handbook outlined procedures for filing grievances, including anonymous submissions and the provision of contact information for the grievance officer, but these were not operationalized or made accessible to residents as required.
Incorrect Coding of Assistive Devices as Restraints
Penalty
Summary
The facility failed to ensure that assistive devices were accurately assessed and not incorrectly coded as restraints for two residents. In the first case, a resident who used a scoop mattress due to poor core control demonstrated the ability to turn, sit up, and get out of bed independently. Both the resident and staff confirmed that the scoop mattress did not restrict movement, and the resident's evaluation noted it was not used as a restraint. However, the Minimum Data Set (MDS) assessments inaccurately coded the scoop mattress as a restraint, despite evidence to the contrary. In the second case, another resident used bed rails as a mobility aid to prevent rolling out of bed and was able to sit and stand independently. Staff confirmed that the bed rails did not limit the resident's mobility or ability to get out of bed. Despite this, the resident's MDS assessments consistently coded the bed rails as being used daily, which was not accurate since they did not function as restraints. These inaccuracies in assessment and documentation led to the deficiency.
Failure to Assess and Document Bed Rail Use as a Restraint
Penalty
Summary
The facility failed to perform and document a complete assessment for the use of bed rails as a restraint for one resident. Observations showed the resident had bed rails in the up position on both sides of the bed and was unable to lower the rail independently due to left-sided paralysis and limited hand mobility following a stroke. The resident reported using the bed rails frequently and stated they prevented him from getting out of bed. Staff interviews confirmed that the resident was assessed and the use of bed rails was discussed, but the documentation did not reflect that the bed rails functioned as a restraint, nor did it indicate that the resident could not remove them independently. Review of the resident's records showed physician orders for bed rails for mobility, but the Assistive Device/Restraint Initial Evaluation did not identify the bed rails as a restraint or document that they limited the resident's movement. The facility's policy defined a restraint as any device the resident cannot remove easily, which restricts freedom of movement, and specified that the definition is based on the resident's functional status. The assessment failed to address these criteria, resulting in incomplete documentation and assessment for the use of bed rails as a restraint.
Failure to Ensure Timely Medication Administration and Adequate Nursing Staff Competency
Penalty
Summary
The facility failed to ensure competent nursing staff were available to provide timely medication administration and to meet residents' physical and psychosocial needs. One resident reported issues with a travel nurse, including concerns about the nurse's attitude and timeliness in completing care. Multiple residents had also complained about the care provided by travel nurses, as documented in resident council meeting minutes. Staff responsible for covering nurse call-offs stated that some travel nurses did not request assistance when running late, resulting in late medication administration. The facility primarily relied on travel nurses due to recruitment challenges, with only one full-time nurse on staff. A review of medication administration records for a resident showed that several medications, including Lisinopril, Cystex, Miralax, and acetaminophen, were administered significantly later than the scheduled times on multiple occasions. Facility policy allows a one-hour window before and after the scheduled time for medication administration, but the medications in question were given well outside this window. The facility's staffing plan and competency requirements were reviewed, but the deficiency was related to the actual practice of timely medication administration and the ability of staff, particularly travel nurses, to meet residents' needs.
Failure to Consistently Manage Pain for Hospice Resident
Penalty
Summary
The facility failed to ensure effective and consistent pain management for a hospice resident, resulting in unnecessary pain and discomfort. Observations and interviews revealed that the resident, who was under hospice care for advanced and progressive disease, received regular doses of ibuprofen and acetaminophen as ordered, but there were concerns from family members and staff regarding delays in administering stronger pain relief, such as morphine. Nursing staff often waited for up to an hour after giving acetaminophen or ibuprofen before considering morphine, even when the resident continued to experience significant pain. Documentation showed that morphine was only administered after repeated requests or when pain persisted despite initial interventions. Review of medication administration records and nursing notes indicated inconsistent documentation of pain assessments and follow-up after pain medication was given. For several months, there was no evidence of regular pain level monitoring, despite a care plan that required pain to be assessed using a 0-10 scale twice daily. When pain was documented, such as shoulder pain rated at 5/10 or 7/10, morphine was not always promptly administered, and family members had to advocate for stronger pain relief. In some instances, morphine was only given after multiple doses of acetaminophen or after direct requests from the resident or family. The facility's hospice plan of care emphasized the goal of relieving or reducing pain and required staff to assess pain characteristics and evaluate responses to medication. However, the records showed that these interventions were not consistently followed, and the resident's pain was not always managed according to the established plan. The lack of timely administration of appropriate pain medication and incomplete documentation of pain assessments contributed to the deficiency in providing adequate comfort and symptom control for the hospice resident.
Inadequate Infection Control Training for Temporary Staff
Penalty
Summary
The facility failed to ensure that temporary agency staff were trained on its infection prevention and control program standards, policies, and procedures. This deficiency was identified through observations, interviews, and record reviews. A traveling CNA, employed for approximately six months, reported that infection control training was not part of her on-board training. During an observation, this staff member did not perform proper hand hygiene. Another traveling employee, hired in mid-August 2024, also stated she did not receive infection control training upon starting. A third traveling employee, employed for about three months, confirmed that infection prevention and control was not included in her orientation. When documentation of infection control training for these staff members was requested, it was confirmed that no such documentation existed.
Failure to Adhere to Standard Precautions in Resident Care
Penalty
Summary
Staff member C failed to adhere to standard precautions related to the use of personal protective equipment and hand hygiene while providing personal care to a resident. During an observation, staff member C donned gloves without sanitizing her hands beforehand and entered the resident's room. She assisted in repositioning the resident and removed a soiled incontinence brief, cleaned the resident's peri area, and disposed of the brief without changing her gloves. Subsequently, she continued to assist with placing a Hoyer lift sling under the resident, removed the resident's clothing, and put on clean clothing, all while still wearing the dirty gloves. Staff member C then placed a clean incontinence brief into the resident's clothing cabinet and used the Hoyer lift to move the resident to a wheelchair, still without changing her gloves. After gathering the garbage, she finally removed the dirty gloves and washed her hands with soap and water. During an interview, staff member C acknowledged that she should have changed her gloves after cleaning the resident and sanitized her hands before donning and after doffing gloves. The facility's policy on standard precautions, last revised in April 2020, requires hand hygiene before and after resident contact and changing gloves to prevent cross-contamination when moving from a dirty task to a clean one.
Inaccurate MDS Coding for Diagnoses and Restraints
Penalty
Summary
The facility failed to ensure accurate coding of MDS assessments for several residents. For one resident, a diagnosis of dementia was added by the physician but was not reflected in the resident's Quarterly MDS. The diagnosis was documented in the resident's EMR only after the survey began, indicating a lack of a fail-safe mechanism to ensure new diagnoses are promptly updated. Staff interviews confirmed the oversight and the absence of a reliable process to update diagnoses after provider visits. Additionally, the facility failed to accurately document the use of bed rails and alarms in the MDS assessments for three other residents. One resident was observed with a chair alarm that was not documented in the MDS, and another resident had a bed rail that was not recorded. Conversely, a third resident's MDS inaccurately indicated the use of a bed rail that was not present. Staff interviews revealed inconsistencies and errors in MDS coding, as well as a lack of updated physician orders regarding the use of alarms and bed rails.
Failure to Update Care Plans for Medical Status and Equipment Usage
Penalty
Summary
The facility failed to revise care plans to reflect the medical status and equipment usage for two residents. For one resident, the physician's order to check blood glucose levels was discontinued on 4/12/24, but the care plan was not updated to reflect this change, leading to a lack of blood sugar monitoring. Additionally, the resident's care plan was not updated to include the use of a wheelchair, which was provided by hospice, despite observations of the resident using the wheelchair in the Day Room and dining room. For another resident, the care plan was not updated to reflect the removal of bed rails, which the resident no longer wanted. The care plan still indicated the use of bed rails, and there was no order obtained to discontinue their use. Staff interviews revealed that the care plans were not updated in a timely manner, and the facility's policy on care plan updates was not followed.
Failure to Implement Bed Rail Intervention and Update Care Plan
Penalty
Summary
The facility failed to implement the intervention of bed rails and update the care plan for a resident. During observations on two separate days, it was noted that the resident did not have bed rails on the bed, despite a physician's order dated several months prior indicating the use of a right bed side rail for bed mobility and repositioning. The resident's care plan also indicated the use of a side rail per the resident's request. Interviews with staff revealed confusion about the presence of bed rails, with one staff member noting that the bed rails were not installed after the resident moved rooms, and another stating that the resident did not want the bed rails anymore, although there was no order to discontinue their use.
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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.
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Nursing homes near Ennis
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tobacco Root Mountains Care Center | 23.5 mi | — | 5 | 1 |
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