Inspection Reports for Chapman Valley Manor
1009 N MARSHALL PO BOX 219, CHAPMAN, KS, 67431
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 18, 2024, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed multiple deficiencies related mainly to medication management, including improper use of psychotropic medications and fentanyl patches, dietary preparation issues, hospice care coordination, and water management concerns. Earlier reports also noted problems with resident safety such as fall prevention and medication errors, as well as care planning, infection control, and environmental sanitation. Complaint investigations were mostly unsubstantiated, except for one substantiated case in 2022 involving inaccurate elopement risk assessment that led to a resident injury. The facility has demonstrated improvement over time by correcting cited deficiencies promptly and maintaining compliance in recent surveys.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
31 residents
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 18, 2024
Visit Reason
An offsite revisit survey was conducted on 10/18/24 to verify correction of all previous deficiencies cited on 09/18/24.
Findings
All deficiencies have been corrected as of the compliance date of 09/24/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Sep 24, 2024
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited in a prior survey conducted on 2024-09-18. The plan outlines corrective actions to address multiple deficiencies related to forms, medication management, dietary services, hospice coordination, and water management.
Findings
The facility identified several deficiencies including incorrect use of CMS forms, improper fentanyl patch management, psychotropic medication renewal issues, dietary preparation concerns, hospice care coordination, and water management risks. The facility has implemented audits, in-services, and monitoring systems to ensure compliance and prevent recurrence.
Deficiencies (7)
Incorrect use of CMS 10055 form by Social Services.
Fentanyl patch orders and placement not properly managed.
PRN Psychotropic Medications lacked proper 14 day stop dates.
Medications given through peg tube were not properly audited to avoid long-acting or enteric-coated forms.
Cook not properly trained on Texture and Consistency-Modified Diets policy.
Care plans for hospice residents not properly updated to reflect coordination with hospice providers.
Water management concerns identified by Maintenance Director.
Report Facts
Plan of Correction monitoring period: 6
Quarterly meetings: 2
Audits: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Jeardoe | Administrator | Administrator involved in in-servicing staff and submitting the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Felicia Majewski | Person who added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 8
Date: Sep 18, 2024
Visit Reason
The inspection was a Health Resurvey to assess compliance with Medicare/Medicaid regulations, including review of Medicaid/Medicare coverage notices, nursing staff competency, medication regimen review, psychotropic medication use, medication errors, food preparation, hospice services coordination, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide correct Medicare ABN forms, inadequate nursing staff competency in medication disposal, failure of consultant pharmacist to identify medication irregularities, improper use of psychotropic medications without required stop dates, medication administration errors crushing extended-release medications, improper preparation of pureed diets, lack of coordinated hospice care plans, and failure to implement a water management program to mitigate Legionella risk.
Deficiencies (8)
Failed to provide correct CMS Form 10055 Advanced Beneficiary Notice to residents R28 and R137, risking uninformed decisions regarding skilled services.
Failed to ensure staff competency in safely disposing of fentanyl patch for resident R29, risking inadequate care.
Consultant Pharmacist failed to identify and report that Resident R26's PRN Haldol medication lacked a 14-day stop date, risking unnecessary psychotropic medication use.
Resident R26's PRN antipsychotic medication lacked a required 14-day stop date, risking unnecessary medication and complications.
Medication error: Staff crushed extended-release Wellbutrin XL medication for Resident R19, risking adverse reactions.
Failed to correctly prepare pureed diets for three residents, risking impaired nutrition and decreased quality of life.
Failed to ensure coordinated hospice care plans between facility and hospice provider for Residents R19 and R29, risking inappropriate end-of-life care.
Failed to conduct risk assessment and implement water management program to mitigate Legionella risk, placing residents at risk for infectious disease.
Report Facts
Census: 31
Residents reviewed: 12
Residents reviewed for medication errors: 5
PRN Haldol medication stop date missing: 1
Medication administration dates: 3
Medication dosage: 150
Pureed diet preparation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified medication errors, nursing competency issues, and hospice care coordination deficiencies |
| Licensed Nurse H | Licensed Nurse | Involved in fentanyl patch incident and disposal |
| Licensed Nurse G | Licensed Nurse | Observed medication administration error with crushed extended-release medication |
| Social Services X | Social Services | Acknowledged incorrect ABN form usage |
| Maintenance Staff U | Maintenance Staff | Reported lack of routine water management checks |
| Certified Medication Aide R | Certified Medication Aide | Administered medication to Resident R26 |
| Dietary Staff BB | Dietary Staff | Prepared pureed diets improperly |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 16, 2024
Visit Reason
An offsite revisit survey was conducted on 02/16/24 to verify correction of all previous deficiencies cited on 01/17/24.
Findings
All deficiencies have been corrected as of the compliance date of 01/24/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Census: 28
Deficiencies: 2
Date: Jan 17, 2024
Visit Reason
The inspection was conducted as an abbreviated survey combined with complaint investigations KS00185063, KS00184799, and KS00183046.
Complaint Details
The visit included complaint investigations KS00185063, KS00184799, and KS00183046 as stated in the initial comments.
Findings
The facility was found deficient in ensuring a safe environment to prevent resident falls, resulting in a resident sustaining a broken nasal bone from a fall due to failure to follow fall interventions. Additionally, a significant medication error occurred when the wrong medication was administered to a resident, placing the resident at risk for health complications.
Deficiencies (2)
Failure to follow Resident 1's fall interventions, resulting in a fall from bed and a broken nasal bone.
Failure to prevent a significant medication error when staff administered amlodipine instead of amiodarone to Resident 2.
Report Facts
Resident census: 28
Fall mat hematoma size: 5
Fall mat hematoma size: 3.5
Medication error duration: 7
Medication dosage: 10
Medication dosage: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide M | Certified Medication Aide | Found Resident 1 lying on the floor after fall. |
| Licensed Nurse G | Licensed Nurse | Documented events surrounding Resident 1's fall and failed to replace fall mat. |
| Certified Medication Aide N | Certified Medication Aide | Stated Resident 1's fall interventions and sensor alarm use. |
| Administrative Nurse D | Administrative Nurse | Expected staff to follow care plans and medication administration rights; notified physician about medication error. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 17, 2024
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited in a prior inspection related to medication errors.
Findings
The facility identified a medication error involving resident R 2, conducted audits, educated staff, and implemented monitoring and competency testing to ensure compliance and prevent recurrence.
Deficiencies (1)
Medication error involving resident R 2 and failure to administer medications correctly.
Report Facts
Dates of corrective actions: Corrective actions occurred on 11/27/23, 11/28/23, 12/6/23, 1/17/24, and 1/24/24
Monitoring period: 6
QAPI review period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Jeardoe | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Felicia Majewski | Added and modified the Plan of Correction | |
| Director of Nursing | Director of Nursing | Completed audits, educated medication aide, and monitored medication pass |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
An offsite revisit survey was conducted on 04/14/23 to verify correction of all previous deficiencies cited on 03/07/23.
Findings
All deficiencies cited in the previous inspection were corrected as of 03/27/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: 0
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 21, 2023
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited during a prior inspection.
Findings
The facility identified multiple deficiencies related to resident care plans, estimated cost notifications, discharge planning, gastrostomy tube care, monitoring of antipsychotics, and infection control. Corrective actions include audits, staff in-service training, policy development, and ongoing monitoring with Quality Assurance/Performance Improvement (QAPI) oversight.
Deficiencies (6)
Failure to ensure residents were informed of the estimated cost (CMS form 10055).
Inadequate comprehensive care plan for resident with gastrostomy tube.
Incomplete review and documentation of stay and post discharge summary for resident.
Failure to update gastrostomy orders to monitor intake of feeding fluids.
Improper monitoring and review of antipsychotic medication usage (Seroquel).
Infection control concerns related to perineal care competency and surveillance.
Report Facts
Plan of Correction completion dates: Mar 23, 2023
Plan of Correction completion date: Mar 27, 2023
Plan of Correction completion date: Mar 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda JearDoe | Administrator | Administrator submitting the Plan of Correction and in-servicing Director of Nursing |
| Felicia Majewski | Added and modified Plan of Correction documentation |
Inspection Report
Routine
Census: 27
Deficiencies: 6
Date: Mar 7, 2023
Visit Reason
The inspection was a health resurvey conducted at the facility to assess compliance with Medicare and Medicaid regulations.
Findings
The facility was found deficient in multiple areas including failure to provide Medicaid beneficiary liability notices with estimated costs, failure to develop comprehensive care plans especially for gastrostomy tube use, failure to develop discharge summaries, inadequate monitoring of tube feeding intake, inappropriate use of psychotropic medications without proper indications, and failure to follow infection prevention and control practices including hand hygiene.
Deficiencies (6)
Failed to provide estimated cost to continue skilled services on CMS form 10055 for two residents.
Failed to develop a comprehensive care plan for gastrostomy tube use for Resident 16.
Failed to develop a discharge summary including recapitulation of stay and post discharge plan for Resident 27.
Failed to monitor amount of intake of feeding and fluids administered through gastrostomy tube for Resident 16.
Failed to document appropriate indications for administration of psychotropic medication for Resident 22.
Failed to provide adequate hand hygiene and glove changing when caring for Residents 9 and 22 during incontinent care.
Report Facts
Census: 27
Residents reviewed: 12
Residents reviewed for unnecessary medications: 5
CMS form 10055 missing cost estimates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of CMS form 10055 cost estimates, care plan deficiencies, and hand hygiene expectations |
| Licensed Nurse G | Licensed Nurse | Administered gastrostomy tube feedings and verified documentation expectations |
| Administrative Nurse E | Administrative Nurse | Verified hand hygiene and glove changing expectations |
| Certified Nurse Aide M | CNA | Observed providing incontinent care without proper hand hygiene |
| Certified Nurse Aide N | CNA | Observed providing incontinent care without proper hand hygiene |
| Certified Nurse Aide O | CNA | Observed providing incontinent care without proper hand hygiene |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 13, 2022
Visit Reason
An offsite revisit survey was conducted on 06/13/22 for all previous deficiencies cited on 05/10/22 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 05/19/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 10, 2022
Visit Reason
The plan of correction addresses deficiencies cited in a prior survey related to elopement risk assessment accuracy and resident safety measures.
Findings
The facility failed to ensure the elopement risk assessment was completed accurately, placing a resident at risk. Corrective actions included medication review, re-education of staff on elopement risk assessments, repair of a door alarm, and implementation of daily safety checks.
Deficiencies (1)
Failure to ensure the elopement risk assessment was completed accurately, placing the resident at risk.
Report Facts
Date of medication review: May 9, 2022
Date PCP signed recommendation: May 10, 2022
Date elopement risk assessments completed for all residents: May 9, 2022
Date of staff re-education completion: May 13, 2022
Date door alarm repaired: May 19, 2022
Plan of correction completion date: May 19, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonita Hicks | Administrator | Submitted plan of correction |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: May 10, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation KS00171507 regarding the facility's nursing staff competencies and resident safety.
Complaint Details
The complaint investigation KS00171507 focused on nursing staff competency and resident safety related to elopement risk. The investigation found that the facility inaccurately assessed a resident's elopement risk, leading to an incident where the resident left the facility unsupervised and was injured.
Findings
The facility failed to ensure the Elopement Risk Assessment was completed accurately and/or updated for a resident at risk for elopement, which placed the resident at risk for injuries related to accidents and hazards. The resident exited the building unsupervised, resulting in injury.
Deficiencies (1)
Failure to ensure the Elopement Risk Assessment was completed accurately and/or updated for a resident at risk for elopement.
Report Facts
Resident census: 31
Incident time: 1135
Incident time: 1146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements regarding resident's prior elopement attempts and door alarm malfunction | |
| Administrative Nurse D | Performed the inaccurate Elopement Assessment for the resident | |
| Certified Nurses Aide M | CNA | Observed resident in dining area and noticed resident missing after incident |
| Licensed Nurse G | LN | Present with CNA M when resident was seen in dining area |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 30, 2021
Visit Reason
An offsite revisit survey was conducted on 09/30/21 to verify correction of all previous deficiencies cited on 09/02/21.
Findings
All deficiencies cited in the previous inspection were corrected as of the compliance date of 09/14/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: 0
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Sep 14, 2021
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited during a prior inspection.
Findings
The facility failed to investigate skin tears, update care plans for safe transfers, follow accident procedures, identify and report lack of blood glucose monitoring, and ensure medication availability and monitoring for adverse reactions. The plan outlines corrective actions including staff re-education, care plan updates, monitoring, and policy revisions.
Deficiencies (5)
Failed to investigate skin tears of unknown injury for one resident.
Failed to update a resident's care plan to reflect the need for assistance of two staff members for safe transfers.
Failed to follow 'Accident or Incident Procedures' when a resident received a skin tear with transfers.
Consultant pharmacist failed to identify and report a resident's lack of blood glucose monitoring.
Failed to ensure a resident's medication was available and failed to monitor the resident for adverse reactions.
Report Facts
Plan of Correction completion dates: Sep 15, 2021
Plan of Correction completion date: Sep 14, 2021
Plan of Correction completion date: Sep 10, 2021
Plan of Correction completion date: Sep 13, 2021
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 5
Date: Sep 2, 2021
Visit Reason
The inspection was a health resurvey conducted to investigate allegations of abuse, neglect, and compliance with care plan and medication regulations.
Complaint Details
The visit was complaint-related due to allegations of abuse, neglect, exploitation, or mistreatment. The facility failed to investigate injuries of unknown origin and did not complete required incident reports or investigations.
Findings
The facility failed to investigate skin tears of Resident 15, failed to update and revise the care plan for Resident 15 after a change in condition, and failed to provide adequate supervision to prevent accidents resulting in skin tears. Additionally, the facility's consultant pharmacist failed to identify and report lack of blood glucose monitoring and insulin unavailability for Resident 16, placing the resident at risk for hypoglycemia/hyperglycemia.
Deficiencies (5)
Failed to investigate Resident 15's skin tears of unknown origin.
Failed to update and revise the care plan for Resident 15 after a change in transfer status.
Failed to provide adequate nursing care and supervision to prevent accidents for Resident 15.
Consultant pharmacist failed to identify and report lack of blood glucose monitoring and insulin unavailability for Resident 16.
Failed to monitor Resident 16's blood glucose and have insulin medication available.
Report Facts
Census: 29
Sample size: 12
Skin tears measurements: 2.3
Skin tears measurements: 1.5
Skin tears measurements: 2
Skin tears measurements: 4
Skin tears measurements: 1.3
Skin tears measurements: 1.5
Blood glucose level: 278
Insulin dose: 3
Days insulin unavailable: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of investigation and care plan updates for Resident 15's skin tears and confirmed insulin issues for Resident 16 |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 07/07/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 14, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-07-02.
Findings
All deficiencies cited in the prior inspection were corrected as of the compliance date 2019-07-31, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 2
Date: Jun 26, 2019
Visit Reason
The visit was a Health Resurvey conducted to assess compliance with regulatory requirements following prior findings.
Findings
The facility failed to discard expired medications in the emergency medication kit and failed to store food in a safe and sanitary manner in the activity refrigerator/freezer, placing residents at risk for ineffective medication use and foodborne illness.
Deficiencies (2)
Failed to discard expired medication in the emergency medication kit located in the facility medication room.
Failed to store food in a safe and sanitary manner in the activity refrigerator/freezer.
Report Facts
Census: 34
Expired Amoxicillin tablets: 8
Expired Coumadin tablets: 3
Undated soda bottles: 6
Bottles of water: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide M | Verified expired medication in emergency medication kit and stated intent to contact pharmacy | |
| Administrative Nurse D | Verified expired medications and contacted local pharmacy for replacement | |
| Activity Director Z | Verified lack of cleaning schedule for refrigerator/freezer | |
| Administrative Nurse DD | Stated staff assigned to clean refrigerator was on leave and cleaning was not routinely done |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 09/24/2018.
Findings
All deficiencies have been corrected as of the compliance date of 10/22/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 6
Date: Sep 24, 2018
Visit Reason
The inspection was a Health Resurvey to assess compliance with Medicare/Medicaid regulations, including review of Medicaid/Medicare coverage notices, nutrition/hydration status, drug regimen reviews, food safety, and environmental conditions.
Findings
The facility failed to provide Advanced Beneficiary Notices to residents discharged from skilled services, failed to adequately monitor and provide hydration to a resident, failed to identify and act on medication documentation irregularities, failed to maintain sanitary food storage and preparation conditions, and failed to maintain a clean and safe environment in resident halls.
Deficiencies (6)
Failed to provide Advanced Beneficiary Notice (ABN) form CMS-10055 to 2 of 3 reviewed residents discharged from skilled services.
Failed to provide adequate fluids and monitor hydration status for 1 sampled resident (#28).
Pharmacist failed to identify and report lack of documentation of daily pulses for 1 sampled resident (#6).
Failed to document daily pulses for 1 sampled resident (#6).
Failed to store, prepare, and serve food in a sanitary manner, including ice buildup in freezers, undated/unlabeled food items, rusted vents, dust, lint, and poor kitchen hygiene.
Failed to provide a clean, sanitary environment on 2 of 3 residential halls, including ceiling damage, water stains, mold, and improper drainage.
Report Facts
Census: 35
Sample size: 14
Residents reviewed for ABN: 3
Residents failed to receive ABN: 2
Days with missing pulse documentation: 16
Fluid intake estimate: 1489
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Verified lack of ABN provision and facility policy |
| Licensed Nurse G | Licensed Nurse | Provided information on fluid administration and pulse documentation |
| Administrative Nurse D | Administrative Nurse | Verified pulse documentation issues and hydration monitoring |
| Dietary Staff CC | Dietary Staff | Verified food safety and kitchen sanitation issues |
| Dietary Staff BB | Dietary Staff | Verified freezer defrost schedule and kitchen sanitation |
| Maintenance Staff U | Maintenance Staff | Verified environmental deficiencies in resident halls |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 24, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 10/22/2018.
Deficiencies (1)
Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Signed letter regarding plan of correction acceptance and facility compliance status. |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 29, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.
Deficiencies (6)
Deficiency related to regulation 483.10(j)(2)-(4)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Deficiency related to regulation 483.45(d)(e)(1)-(2)
Deficiency related to regulation 483.60(i)(1)-(3)
Deficiency related to regulation 483.45(c)(1)(3)-(5)
Deficiency related to regulation 483.80(a)(1)(2)(4)(e)(f)
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 6
Date: Mar 20, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #113172 to evaluate compliance with resident rights, safety, medication administration, food safety, infection control, and other regulatory requirements.
Complaint Details
The inspection included a complaint investigation (#113172) related to missing personal property and other concerns.
Findings
The facility was found deficient in multiple areas including failure to ensure an effective system to respond to residents' missing personal property, failure to secure chemicals safely, failure to administer medications as ordered, failure to dispose of expired food, failure of the pharmacy consultant to identify medication irregularities, and failure to follow infection control precautions by housekeeping staff.
Deficiencies (6)
Failed to ensure an effective system to respond to residents' missing personal property for 1 of 3 residents reviewed.
Failed to secure chemicals in a safe manner, leaving hazardous chemicals unlocked and accessible.
Failed to administer medications as ordered for Resident #28; resident received double the ordered dose of milk of magnesia.
Failed to dispose of outdated food items in the kitchen.
Pharmacy consultant failed to identify medications in excessive dose for Resident #28.
Failed to utilize infection control precautions; housekeeping staff did not change gloves between resident rooms and dripped water from toilet brush onto floor.
Report Facts
Census: 39
Residents sampled: 12
Residents sampled for medication review: 5
Milk of magnesia administration count: 51
Cognitively impaired residents: 19
Expired food items: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Provided statements regarding resident property handling and inventory procedures | |
| Social Services Designee K | Described inventory and property pick-up procedures | |
| Nurse J | Described procedures for resident belongings after death | |
| Housekeeping staff B | Observed leaving chemicals unsecured and not changing gloves between rooms | |
| Housekeeping supervisor C | Stated expectation for housekeeping staff to change gloves between rooms | |
| Direct care staff F | Confirmed medication administration for Resident #28 | |
| Direct care staff E | Stated resident #28 did not have bowel movement issues | |
| Licensed care staff G | Provided information on resident #28's bowel issues and facility policies | |
| Administrative nursing staff H | Confirmed medication administration and verbal order for Resident #28 | |
| Dietary Staff D | Reported expired food items and attempts to contact supplier |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 20, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective March 29, 2017.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Named as the signatory and contact person regarding the survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 20, 2017
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited during the inspection conducted on 2017-03-20.
Findings
The plan addresses multiple deficiencies including improper disposal of resident property, unsecured chemicals, medication administration errors, expired food disposal, monthly drug regimen reviews, and infection control precautions to prevent transmission of infection.
Deficiencies (6)
Failure to properly dispose of resident property after discharge or death.
Failure to keep chemicals in view and/or secure at all times.
Medication not administered as ordered per physician.
Failure to dispose of expired food in facility kitchen.
Licensed pharmacist did not perform monthly drug regimen review on every resident.
Inadequate precautions to prevent transmission of infection.
Report Facts
Deficiency completion dates: Various completion dates ranging from 2017-03-21 to 2017-04-04 for corrective actions
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela K. Sheets | Administrator | Submitted the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 11, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at 'E' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found at 'E' level with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Nov 11, 2016
Provider agreement termination date: Feb 11, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 31, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that corrections were completed for deficiencies identified under regulations 483.10(e), 483.75(l)(4), 483.15(e)(2), and 483.20(d), 483.20(k)(1) as of 08/31/2015.
Deficiencies (3)
Deficiency related to regulation 483.10(e), 483.75(l)(4)
Deficiency related to regulation 483.15(e)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Report Facts
Deficiencies corrected: 3
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 27, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found isolated 'D' level deficiencies that constitute no actual harm but have the potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective August 31, 2015.
Deficiencies (1)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter. |
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 3
Date: Aug 27, 2015
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements related to resident privacy, notification of room changes, and development of comprehensive care plans.
Findings
The facility was found deficient in maintaining resident privacy during toileting, failing to notify and document room changes for residents, and not developing comprehensive care plans for two residents, including lack of care planning for behavioral medications and individualized activities.
Deficiencies (3)
Failed to provide privacy for one resident during toileting when window blinds were not closed.
Failed to document notification to a resident regarding room change.
Failed to develop comprehensive care plans for two residents, including lack of care plan for Clonazepam medication and individualized activities.
Report Facts
Census: 43
Sample size: 11
Residents with deficient care plans: 2
Residents reviewed for room change notification: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff O and P | Assisted resident #39 during toileting and failed to close window blinds | |
| Licensed nursing staff H | Stated staff should ensure privacy by closing curtains and noted lack of care plan for Clonazepam | |
| Administrative staff D | Expected staff to ensure privacy and stated family notification should occur for room changes | |
| Direct care staff Q | Interviewed regarding resident's confusion and depression | |
| Administrative nursing staff C | Interviewed about care planning for Clonazepam and activities | |
| Activities staff AA | Interviewed about specific activities for resident care plan |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 27, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to ensuring privacy for dependent residents, documenting notification of room changes in medical records, and having comprehensive care plans for all residents including behavior sheets and individualized activity plans.
Deficiencies (3)
The facility will ensure privacy for all dependent residents by closing blinds and curtains during direct care and toileting.
The facility will document notification of room changes in the residents' medical records.
The facility will have a comprehensive care plan for all residents, including behavior sheets for residents on anti-anxiety medication and individualized activity plans.
Report Facts
Complete Date for F0000: Sep 16, 2015
Complete Date for F164-D: Aug 27, 2015
Complete Date for F247-D: Aug 27, 2015
Complete Date for F279-D: Aug 31, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Pamela Sheets | Administrator | Submitted the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 13, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.
Deficiencies (1)
Deficiencies found at 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Aug 13, 2015
Provider agreement termination date: Nov 13, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: May 13, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers F0241, F0279, F0281, and F0441 were corrected as of the revisit date.
Deficiencies (4)
Deficiency identified under regulation 483.15(a) (F0241)
Deficiency identified under regulations 483.20(d) and 483.20(k)(1) (F0279)
Deficiency identified under regulation 483.20(k)(3)(i) (F0281)
Deficiency identified under regulation 483.65 (F0441)
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 4
Date: May 8, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in promoting dignity and respect by leaving incontinent pads on recliners not in use, failing to develop a comprehensive care plan for a resident using bilateral side rails, lack of follow-up assessments after administration of as needed medications, and inadequate infection control practices including improper cleaning of resident rooms and failure to disinfect the glucometer between uses.
Deficiencies (4)
Failure to promote dignity and respect by not removing incontinent pads from recliners in the living area on multiple days.
Failure to develop a comprehensive care plan for a resident using bilateral quarter side rails at the resident's request.
Failure to provide and arrange services to meet professional standards by lack of follow-up after administration of as needed medications for one resident.
Failure to establish and maintain an infection control program including improper cleaning of resident rooms and failure to disinfect glucometer between uses.
Report Facts
Residents present: 45
Sampled residents: 15
Residents reviewed for unnecessary medications: 5
Diabetic residents using glucometer: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse C | Administrative Nurse | Verified dignity concerns, care plan omissions, medication follow-up requirements, and infection control deficiencies |
| Nurse A | Nurse | Observed performing blood glucose fingerstick without disinfecting glucometer |
| Medication Aide F | Medication Aide | Administered as needed medications and stated follow-up checks with residents |
| Nurse G | Nurse | Verified medication aide monitoring practices |
| Housekeeping Staff B | Housekeeping Staff | Observed cleaning resident bathroom surfaces improperly |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 13, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date of 05/13/2013.
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 1, 2013
Visit Reason
This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies related to physician notification, resident dignity during care, skin assessments, medication management, infection control, and sanitary environment practices.
Deficiencies (7)
Failure to notify physician and legal representative timely for incidents requiring intervention.
Staff not providing eating assistance and insulin administration in private areas.
Inadequate care and reassessments for maintaining resident skin condition.
Residents receiving unnecessary drugs and lack of medication monitoring.
Failure to administer medications as ordered and improper medication labeling.
Pharmacy consultant not reporting drug irregularities to physician or DON.
Unsanitary environment and improper handling of oxygen tubing and glucometer disinfecting.
Report Facts
Complete Date: May 8, 2013
Complete Date: May 1, 2013
Complete Date: Apr 23, 2013
Complete Date: Apr 29, 2013
Complete Date: Apr 25, 2013
Complete Date: Apr 30, 2013
Complete Date: May 13, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Pamela Sheets | Administrator | Submitted the Plan of Correction to KDADS |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Routine
Census: 42
Deficiencies: 9
Date: Apr 22, 2013
Visit Reason
Routine health facility survey to assess compliance with federal regulations and standards for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify a resident's physician of a change in skin condition, failure to promote dignity during meals, inadequate monitoring of blood pressure for a resident on medication, improper medication labeling and administration, failure to report drug irregularities, and inadequate infection control practices including improper disinfection of glucometer and improper storage of oxygen tubing.
Deficiencies (9)
Failed to notify resident's physician regarding a change in the resident's skin condition (Resident #45).
Failed to promote dignity and respect during meals for residents requiring assistance (Resident #42 and others).
Failed to provide privacy during insulin administration in public areas.
Failed to provide necessary care and services to maintain highest well-being, including reassessment and treatment of skin condition (Resident #45).
Failed to ensure drug regimen free from unnecessary drugs; inadequate blood pressure monitoring for Resident #42 on Lisinopril.
Failed to ensure accurate medication procedures; improper labeling of medications and incorrect administration of narcotic medication.
Failed to ensure pharmacist reviewed drug regimen monthly and reported irregularities regarding blood pressure monitoring for Resident #42.
Failed to maintain infection control program; inadequate disinfection of glucometer between residents, improper storage of oxygen tubing, and failure to properly dispose of bio-hazardous trash.
Failed to promote adequate hand hygiene and infection control related to resident with psoriasis and staff handling skin wounds.
Report Facts
Deficiencies cited: 9
Resident census: 42
Sample size: 18
Blood pressure last recorded: 11256
Insulin units: 65
Medication dose: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Verified medication labeling issues and insulin administration privacy concerns; verified lack of blood pressure monitoring for Resident #42. | |
| Nurse A | Administrative Nurse | Verified weekly skin assessments, lack of treatment for psoriasis, and infection control issues. |
| Nurse D | Verified worsening skin condition and lack of physician notification for Resident #45. | |
| Wound Nurse C | Verified skin assessment documentation and need for physician notification for Resident #45. | |
| Medication Aide G | Administered medications improperly and identified medication by familiarity rather than label. | |
| Nurse C | Observed glucometer use and cleaning practices. | |
| Nurse Aide E | Verified resident scratching behavior and staff reporting requirements. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 7, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection, specifically addressing maintenance of the call light system.
Findings
The facility identified deficiencies related to the call light system and has planned corrective actions including monthly maintenance checks and policy updates to ensure proper functioning.
Deficiencies (1)
Call light system not in proper working condition
Report Facts
Date of Compliance: Mar 7, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 1
Date: Feb 28, 2012
Visit Reason
The inspection was a health facility resurvey to assess compliance with regulatory requirements, specifically focusing on the functionality of the resident call system.
Findings
The facility failed to ensure the nurse call system worked effectively and efficiently on 2 of the 3 halls. Observations revealed that several resident bedroom and bathroom call lights failed to signal at the nurse's station and on handheld pagers. Maintenance staff confirmed no routine checks were performed on the call light system.
Deficiencies (1)
The nurse call system was not functioning properly on 2 of the 3 halls, failing to signal resident calls at the nurse's station and on handheld pagers.
Report Facts
Census: 47
Deficiency count: 1
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N021001 POC V7YL11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses multiple deficiencies including improper use of incontinent pads, lack of comprehensive care plans for residents using bilateral side rails, inadequate follow-up on PRN narcotic efficacy by licensed nurses, and insufficient sanitation practices related to resident rooms and glucometer disinfection.
Deficiencies (4)
Incontinent pads left on living room furniture.
Lack of comprehensive care plan for residents using bilateral side rails.
Failure to ensure licensed nurses follow up on efficacy of PRN narcotic medications.
Failure to provide a sanitary environment to prevent disease transmission, including improper cleaning of resident rooms and glucometer disinfection.
Report Facts
Deficiency completion dates: May 12, 2014
Deficiency completion date: May 13, 2014
QA/QI committee review date: May 28, 2014
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N021001 POC XHWI11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The facility had deficiencies related to expired medicines in the emergency medication kit and cleanliness issues with refrigerators. The Plan of Correction outlines actions taken to replace expired medications, implement monthly checks, and clean and monitor refrigerators to sustain compliance.
Deficiencies (2)
Expired medicines Amoxicillin 250 mg and Coumadin 5 mg found in facility emergency medication kit.
Activity/Family room refrigerator and freezer were not clean; undated or unlabeled food present.
Report Facts
Complete Date for corrective actions: Jul 31, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cassidy | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N021001 POC 4DOT11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The Plan of Correction outlines specific corrective actions for multiple deficiencies including skilled nursing discharge procedures, staff competency and education, medication order reviews, kitchen sanitation, and facility maintenance issues.
Deficiencies (6)
Failure to provide CMS ABN form 10055 to residents ending skilled nursing services.
Failure to ensure dependent residents receive adequate fluids at meals and during care.
Physician orders for resident #6 not properly reviewed or documented regarding cardiac arrhythmia medication administration.
Physician orders for resident #6 not properly reviewed or documented regarding cardiac arrhythmia medication administration (duplicate entry).
Kitchen sanitation issues including defrosting freezers, discarding unlabeled food, cleaning vents and surfaces, and staff education on hairnet use.
Ceiling panel replacements, drainage pipe extensions, ceiling repairs, air vent cleaning, and implementation of preventative maintenance policy.
Report Facts
Complete Date: Oct 22, 2018
Event ID: 4DOT11
Viewing
Loading inspection reports...
