Inspection Reports for Garden Valley Retirement Village
1505 E SPRUCE STREET, KS, 67846-6296
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 18, 2015, found no deficiencies after verifying that previously cited issues had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to resident care, including wound care, dignity, bathing preferences, pain management, infection control, and safety maintenance. Complaint investigations substantiated failures in medication administration, infection control, privacy, and care services, but enforcement actions were limited to a denial of payment for new Medicare admissions in 2015 due to deficiencies at a 'G' level; no fines or license suspensions were listed in the available reports. Prior plans of correction addressed these concerns with staff education, monitoring, and systemic changes. The facility’s record shows improvement over time, with the most recent inspections confirming correction of prior deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
26.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
347% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
73 residents
Based on a April 2015 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 18, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously identified deficiency with ID prefix S1364 and regulation 26-40-305 (3) was corrected on 2015-05-23. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency identified by regulation 26-40-305 (3) with ID prefix S1364 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 8
Jun 18, 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
All previously cited deficiencies listed with their regulation numbers were corrected as of 05/23/2015, indicating compliance with the required standards.
Deficiencies (8)
| Description |
|---|
| Deficiency identified under regulation 483.15(a) |
| Deficiency identified under regulations 483.20(d)(3) and 483.10(k)(2) |
| Deficiency identified under regulation 483.25 |
| Deficiency identified under regulation 483.25(a)(2) |
| Deficiency identified under regulation 483.25(c) |
| Deficiency identified under regulation 483.25(h) |
| Deficiency identified under regulation 483.35(i) |
| Deficiency identified under regulation 483.65 |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 12
May 23, 2015
Visit Reason
This document is a Plan of Correction submitted by Garden Valley Retirement Village to address deficiencies cited in a prior inspection report (2567). It outlines corrective actions to be taken to maintain substantial compliance with state and federal regulations.
Findings
The Plan of Correction details multiple deficiencies related to resident care, including wound care, dignity in care, bathing preferences, maintenance issues, pain management, therapy services, pressure ulcer prevention, fall investigations, infection control, and equipment safety. The facility describes systemic changes and monitoring plans to prevent recurrence of these deficiencies.
Severity Breakdown
D: 5
E: 1
G: 3
F: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Significant change to resident #101's pressure ulcers on heels requiring physician consultation and weekly interdisciplinary review. | D |
| Failure to provide care enhancing resident #97's dignity, requiring staff education and care plan revisions. | D |
| Inadequate honoring of resident bathing choices and code status, requiring care plan updates and staff education. | D |
| Maintenance and housekeeping deficiencies requiring repairs, painting, and cleaning with monitoring added to preventative maintenance logs. | E |
| Inadequate wound care plans for resident #101 and others, requiring weekly interdisciplinary review and Director of Nursing audits. | D |
| Pain management and dialysis translation services deficiencies for residents #112 and #75, requiring monitoring and physician contact. | G |
| Therapy services follow-up for resident #101 and others discharged from therapy, requiring restorative program implementation. | D |
| Pressure ulcer prevention and treatment care plan updates for residents #70 and #101, including Braden Scale assessments and weekly skin measurements. | G |
| Fall investigation process revision and care plan updates for resident #112 and others at risk, including root cause analysis and QAPI review. | G |
| Installation and maintenance of appropriate air gap for ice maker drainage on skilled nursing unit. | F |
| Infection control deficiencies including proper handling of linens, dressing changes, and disposal of infectious bandages, with staff education and monitoring. | F |
| Replacement of hydrocollator outlet with GFCI outlet to prevent hazard, with ongoing maintenance monitoring. | F |
Report Facts
Completion date: May 23, 2015
Number of residents referenced: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J Stephenson | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Apr 23, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at 'G' level, resulting in enforcement remedies including denial of payment for new Medicare admissions effective July 23, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found at 'G' level | G |
Report Facts
Denial of payment effective date: Jul 23, 2015
Compliance deadline: Oct 23, 2015
Civil Money Penalty threshold: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Stephenson | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions in the letter |
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 1
Apr 16, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with electrical safety requirements in the facility.
Findings
The facility failed to ensure the resident environment was free from accident hazards by not installing a ground-fault circuit interrupter (GFCI) outlet for the hydrocollator in the rehabilitation room.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to install a GFCI outlet for the hydrocollator in the rehabilitation room. | SS=F |
Report Facts
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff R mentioned regarding the GFCI outlet status |
Inspection Report
Life Safety
Deficiencies: 1
Sep 4, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Dec 4, 2014
Provider agreement termination date: Mar 4, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Schulte | Administrator | Named as facility administrator in the report |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
| Joe Ewert | Commissioner | Mentioned as Commissioner of KDADS |
Inspection Report
Follow-Up
Deficiencies: 1
Feb 24, 2014
Visit Reason
This is a post-certification revisit to verify that previously identified deficiencies have been corrected as of the revisit date.
Findings
The report confirms that the deficiency identified under regulation 483.60(a),(b) with ID prefix F0425 was corrected by 02/24/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.60(a),(b) previously cited and corrected. |
Report Facts
Deficiency correction date: Feb 24, 2014
Inspection Report
Follow-Up
Deficiencies: 9
Feb 20, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the initial survey were corrected.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies were corrected as of the revisit date.
Deficiencies (9)
| Description |
|---|
| Deficiency with regulation 483.15(c)(6) |
| Deficiency with regulation 483.20(i) |
| Deficiency with regulation 483.20(d), 483.20(k)(1) |
| Deficiency with regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency with regulation 483.25(a)(2) |
| Deficiency with regulation 483.25(d) |
| Deficiency with regulation 483.25(h) |
| Deficiency with regulation 483.35(i) |
| Deficiency with regulation 483.65 |
Inspection Report
Plan of Correction
Deficiencies: 10
Feb 20, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address and correct deficiencies cited in a prior inspection related to compliance with Federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions for multiple deficiencies including resident grievance handling, care plan accuracy for bowel and bladder programs, bathing preferences, infection control techniques, safety measures, and sanitary serving practices. The facility commits to audits, staff education, and ongoing monitoring to ensure compliance.
Deficiencies (10)
| Description |
|---|
| Failure to listen to and act upon grievances and recommendations of residents and families concerning resident care and life in the facility. |
| Assessments did not accurately reflect residents' status; bowel and bladder programs and urinary incontinence care plans were incomplete or missing. |
| Care plans for residents' activities preferences were not written or updated. |
| Resident's care plan not updated to include fall prevention intervention (use of dycem in wheelchair). |
| Resident bathing preferences and schedules were not properly documented or followed. |
| Direct Care Staff J lacked proper infection control technique education and monitoring. |
| Maintenance issues with door locking mechanism and unsecured storage of harmful liquids. |
| Dietary staff lacked education on sanitary serving techniques and proper storage of dishware. |
| Licensed staff lacked education on infection control techniques including use of barriers and gloves. |
| Linen and trash containers in soiled utility and laundry rooms were not covered with tight fitting lids and staff were not properly in-serviced. |
Report Facts
Date for completion of corrective actions: Feb 20, 2014
Resident numbers referenced: 19
Resident numbers referenced: 101
Resident numbers referenced: 103
Resident number referenced: 67
Resident number referenced: 89
Date for bathing schedule implementation: Feb 3, 2014
Date for infection control education completion: Feb 20, 2014
Date for door lock repair: Jan 13, 2014
Date for cabinet installation: Feb 20, 2014
Date for dietary staff education: Jan 15, 2014
Date for glove use education: Feb 13, 2014
Date for licensed staff education: Jan 17, 2014
Date for linen container coverage: Jan 16, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff J | Educated on proper infection control techniques and monitored | |
| Dietary Staff DD | Educated on sanitary serving techniques and monitored | |
| Licensed Staff H | Educated on infection control techniques including barrier use and glove use | |
| Licensed Staff I | Educated on infection control techniques including barrier use and glove use |
Inspection Report
Re-Inspection
Deficiencies: 2
Feb 20, 2014
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that two specific deficiencies identified by regulation numbers 26-40-302 (6)(a)(b) and 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) were corrected as of 02/20/2014.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-40-302 (6)(a)(b) |
| Deficiency related to regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Feb 10, 2014
Visit Reason
The inspection was conducted as an abbreviated survey for complaint investigation #KS00072076 regarding failure to provide ordered medications to a resident.
Findings
The facility failed to obtain and provide routine medications, including pain medication Norco and Lipitor, to Resident #4 as ordered by the physician, resulting in the resident experiencing unmanaged pain for approximately 18 hours after admission.
Complaint Details
The complaint investigation found substantiated failure to provide timely pain medication and other ordered drugs to Resident #4, resulting in significant pain and distress.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain/provide routine drugs to 1 of 4 sampled residents as ordered by the physician (Resident #4). | SS=D |
Report Facts
Resident census: 73
Residents sampled: 4
Hours delay: 18
Days medication omitted: 2
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Jan 22, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #70860 to assess compliance with facility regulations regarding soiled workroom and laundry service practices.
Findings
The facility failed to properly cover soiled linen and trash receptacles on multiple days during the survey. Observations revealed uncovered trash receptacles and soiled linen containers, and the facility lacked policies for trash and linen handling.
Complaint Details
The visit was triggered by a complaint investigation #70860. The facility was found to have deficiencies related to improper covering of soiled linen and trash receptacles, and lack of policies for trash and linen handling.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to properly cover soiled linen and trash receptacles on 2 of 4 days on site of the survey. | SS=E |
| Failed to properly cover soiled linen in the laundry receiving area with lids hanging above open barrels. | SS=E |
Report Facts
Census: 70
Sample size: 16
Days of non-compliance: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor Y | Acknowledged that trash, unbagged linen containers, and laundry receptacle containers were not covered with tight-fitting lids. |
Inspection Report
Follow-Up
Deficiencies: 2
Dec 4, 2012
Visit Reason
This report documents a revisit conducted to verify that previously identified deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit report confirms that the deficiencies previously cited under regulations 26-40-303 (k)(l)(m)(n) and 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) were corrected as of 11/02/2012.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-40-303 (k)(l)(m)(n) |
| Deficiency related to regulation 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) |
Report Facts
Deficiency correction date: Nov 2, 2012
Inspection Report
Follow-Up
Deficiencies: 12
Dec 4, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously cited deficiencies were corrected by 11/02/2012, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (12)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(b)(2)(ii) |
| Deficiency related to regulation 483.20(g) - (j) |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.30(a) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.70(h) |
| Deficiency related to regulation 483.75(e)(8) |
Report Facts
Deficiencies corrected: 12
Inspection Report
Census: 73
Deficiencies: 2
Oct 10, 2012
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to dietary services and nursing facility support systems, including the functionality of ice machines and call light systems.
Findings
The facility failed to ensure the ice machine dispensed ice directly into a container for resident self-serve and failed to maintain functional visual and audible signals on the call light system at the nursing stations and soiled utility rooms.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The ice machine accessible to residents did not dispense ice directly into a container, requiring staff to scoop ice manually. | SS=E |
| The call light system failed to produce a visual signal on the enunciator panel for a sampled resident and failed to produce functional visual and audible signals in both soiled utility rooms. | SS=E |
Report Facts
Census: 73
Inspection Report
Plan of Correction
Deficiencies: 12
Oct 4, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection related to compliance with Federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions for multiple deficiencies including resident rights notification, completion of care assessment summaries and care plans, hospice service coordination, restorative nursing program compliance, water temperature safety, medication management with black box warnings, staffing adequacy, food safety and sanitation, in-service training for nurse aides, ice machine safety, and resident call system functionality.
Severity Breakdown
D: 4
E: 5
F: 3
K: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and rules in a language they understand and notify them of demand bill rights when payer source changes. | D |
| Incomplete care assessment summaries and comprehensive nursing care plans for residents. | E |
| Incomplete comprehensive assessments and care plans for residents receiving hospice services. | D |
| Inaccurate assessment and care plan for a resident's Stage II Pressure Ulcer. | D |
| Noncompliance with restorative nursing program requirements and documentation. | D |
| Unsafe water temperatures due to lack of check valve and mixing valve issues. | K |
| Care plans not updated to include black box warnings and medication side effects for multiple residents. | E |
| Insufficient staffing to meet residents' needs and failure to ensure adequate staff training and retention. | F |
| Failure to procure and maintain food under sanitary conditions, including kitchen ceiling cleanliness and infection control training. | F |
| Failure to provide sufficient in-service training to nurse aides to ensure continuing competence. | F |
| Ice machines not dispensing ice directly into containers and being accessible to residents. | E |
| Resident call system malfunctioning, including nonfunctional call light panels and ability to silence call lights improperly. | E |
Report Facts
Audit frequency: 5
In-service training hours: 12
Water temperature range: 98
Water temperature range: 120
Date of check valve installation: Oct 4, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cherise Salas | Business Office Manager | Submitted the Plan of Correction document. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 3
Sep 15, 2012
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 corrections were completed for deficiencies identified under regulations 483.10(e), 483.75(l)(4), 483.25(h), and 483.65 as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 483.10(e), 483.75(l)(4) |
| Deficiency under regulation 483.25(h) |
| Deficiency under regulation 483.65 |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Aug 17, 2012
Visit Reason
The inspection was an abbreviated survey conducted in response to complaint #KS 00059037.
Findings
The facility failed to provide personal privacy for residents, failed to ensure adequate supervision and use of assistive devices to prevent accidents, and failed to maintain infection control standards including proper sanitization of shower equipment and hand hygiene among staff.
Complaint Details
The survey was conducted as an abbreviated survey for complaint #KS 00059037.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide personal privacy for 2 of 4 residents when staff opened the main door to the resident's room while the resident sat in the bathroom with the bathroom door open, exposing the resident to staff, residents, and public view. | SS=D |
| Failed to ensure 1 of 4 residents reviewed for falls received adequate supervision and assistive devices to prevent accidents when staff failed to use a gait belt for transfers and failed to use a chair alarm as directed by the resident's care plan. | SS=D |
| Failed to establish and maintain an infection control program to prevent the spread of infection, including failure to effectively sanitize shower equipment between residents and failure of staff to wash hands or change gloves after direct resident contact. | SS=F |
Report Facts
Census: 70
Residents sampled: 7
Residents sampled for privacy: 4
Residents sampled for falls: 4
Fall Risk assessment score: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Named in findings related to failure to provide privacy and failure to use gait belt during transfers. | |
| Staff K | Named in findings related to failure to provide privacy and failure to use gait belt during transfers. | |
| Licensed staff G | Licensed nursing staff | Provided statements regarding expectations for privacy, use of gait belts, chair alarms, and hand hygiene. |
| Administrative nursing staff B | Administrative nursing staff | Provided statements regarding expectations for privacy, use of gait belts, chair alarms, and hand hygiene. |
| Direct Care Staff C | Observed failing to allow disinfectant to remain on shower surfaces for required time. | |
| Staff L | Observed failing to properly sanitize shower equipment and failing to scrub surfaces as per instructions. | |
| Staff M | Observed failing to place chair alarm and failing to wash hands before putting on gloves. | |
| Staff O | Observed providing pericare and removing gloves. |
Inspection Report
Plan of Correction
Deficiencies: 3
Aug 17, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Findings
The plan addresses deficiencies related to resident privacy, accident hazard prevention, and infection control. The facility outlines corrective actions including staff education, monitoring, and audits to ensure compliance by 09/15/2012.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Garden Valley 081712 Complaint.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide personal privacy and confidentiality during personal care. | D |
| Failure to ensure resident environment is free of accident hazards and provide adequate supervision and assistive devices. | D |
| Failure to maintain infection control by providing a safe, sanitary, and comfortable environment to prevent disease and infection. | F |
Report Facts
Completion date: Sep 15, 2012
Education date: Sep 6, 2012
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 3
Jul 31, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.25, 483.25(a)(2), and 483.25(l) were corrected as of 07/31/2012.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(l) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Jul 5, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on allegations identified in Complaint Investigations #KS00056899 and #KS00058112.
Findings
The facility failed to provide necessary care and services to maintain residents' highest well-being, including pain management for Resident #5, appropriate restorative nursing services for Residents #1, #2, #3, and #4, and failed to monitor for adverse effects of multiple medications causing excessive drowsiness in Resident #5.
Complaint Details
The inspection was triggered by complaints identified in Complaint Investigations #KS00056899 and #KS00058112.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide necessary care and services for pain management for Resident #5. | SS=D |
| Failure to provide appropriate treatment and services to maintain or improve ADLs for Residents #1, #2, #3, and #4. | SS=E |
| Failure to ensure drug regimen is free from unnecessary drugs for Resident #5 due to inadequate monitoring of adverse effects and excessive drowsiness. | SS=D |
Report Facts
Residents sampled: 9
Residents reviewed for pain issues: 3
Residents reviewed for restorative nursing services: 4
Medication administration dates: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse E | Licensed Nurse | Reported not being informed of Resident #5's pain complaints during transfer and later assessed and administered pain medication. |
| Direct Care Staff G | Direct Care Staff | Observed ignoring Resident #5's pain expressions during transfer. |
| Direct Care Staff J | Direct Care Staff | Observed ignoring Resident #5's pain expressions during transfer and reported resident sleeps most of the day. |
| Restorative Staff L | Restorative Nursing Staff | Reported on restorative nursing programs and resident participation. |
| Administrative Nurse B | Administrative Nurse | Provided information on residents' ADL declines and restorative nursing program status. |
| Direct Care Staff D | Direct Care Staff | Reported on resident #2's increased assistance needs and restorative nursing activities. |
| Direct Care Staff I | Direct Care Staff | Reported on resident #4's condition and sleeping patterns of resident #5. |
| Licensed Nurse C | Licensed Nurse | Confirmed resident #4 placed on walk to dine restorative program. |
| Activity Staff M | Activity Staff | Present during group exercise session but did not engage sleeping residents. |
Inspection Report
Plan of Correction
Deficiencies: 3
Jul 5, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation.
Findings
The facility identified deficiencies related to pain management, therapy and restorative care, and medication regimen issues. Corrective actions include resident-specific evaluations, staff in-services, audits, and ongoing monitoring by the Director of Nursing and Quality Assurance Committee.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Garden Valley 070512 Complaint.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being (pain management). | D |
| Failure to offer appropriate treatment and services to maintain or improve resident abilities (therapy and restorative care). | E |
| Failure to assure each resident's drug regimen is free from unnecessary drugs. | D |
Report Facts
Complete Date: Jul 31, 2012
Staff in-service date: Jul 5, 2012
Pharmacy review date: Jul 13, 2012
Physician contact date: Jul 16, 2012
Inspection Report
Follow-Up
Deficiencies: 6
Aug 18, 2011
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.20, 483.25, 483.35, and 483.60 were corrected as of the revisit date.
Deficiencies (6)
| Description |
|---|
| Deficiency related to regulation 483.20, 483.20(b) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(a),(b) |
Report Facts
Deficiencies corrected: 6
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 6
Jul 19, 2011
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation (#49137) at Garden Valley Retirement Village.
Findings
The facility failed to conduct comprehensive and accurate assessments, develop comprehensive care plans, provide necessary care and services for residents' skin and bladder conditions, maintain sanitary food preparation and storage conditions, and ensure timely administration of medications.
Complaint Details
The inspection was triggered by a complaint investigation #49137.
Severity Breakdown
SS=D: 5
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to conduct initial and periodic comprehensive and accurate assessments for 3 of 19 sampled residents related to incontinence and skin conditions. | SS=D |
| Failed to develop comprehensive care plans for 2 of 19 residents related to incontinence and skin problems. | SS=D |
| Failed to provide necessary care and services to attain or maintain the highest practicable physical well-being for 2 of 3 residents sampled for non-pressure related skin conditions. | SS=D |
| Failed to ensure that 2 of 3 residents sampled for incontinence received appropriate treatment and services to restore as much normal bladder function as possible. | SS=D |
| Failed to store and prepare food under sanitary conditions in two kitchens, including issues with food labeling, cleanliness, and sanitizer levels. | SS=F |
| Failed to have a system in place to ensure timely acquisition and administration of medications for one resident. | SS=D |
Report Facts
Census: 65
Sampled residents: 19
Incontinent episodes: 10
Incontinent episodes: 5
Skin tear size: 3
Wound size: 15
Sanitizer concentration: 30
Medication administration delay: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse C | Licensed Nurse | Confirmed computer automatically put check marks in assessment boxes without further assessments. |
| Licensed nurse J | Licensed Nurse | Unaware of skin tear on resident #28 and confirmed no treatment or ongoing assessment. |
| Licensed nurse L | Licensed Nurse | Changed dressing on resident #102's wound and confirmed lack of care plan and treatment record instructions. |
| Licensed nurse K | Licensed Nurse | Confirmed lack of care plan related to resident #97's incontinence. |
| Administrative nurse A | Administrative Nurse | Stated resident #97 should have a toileting plan and confirmed confusion about wound care for resident #102. |
| Dietary staff N | Dietary Staff | Acknowledged staff had not been checking sanitizer correctly and confirmed cleaning schedules. |
| Dietary staff O | Dietary Staff | Stated standing fan in kitchen had not been on cleaning schedule. |
Inspection Report
Plan of Correction
Deficiencies: 1
N028002 POC ZJQH11
Visit Reason
This document is a plan of correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Findings
The plan of correction addresses medication management deficiencies, including ensuring all medications for Resident #4 are in the facility, providing one-on-one training for licensed nurses on proper medication ordering procedures, and auditing medication timeliness for new admissions with monthly reporting to Quality Assurance.
Complaint Details
This plan of correction is related to a complaint investigation identified as Garden Valley 021014 Complaint.
Deficiencies (1)
| Description |
|---|
| Medication management issues related to ordering and availability of medications for new admissions. |
Report Facts
Complete Date for F0000 Plan of Correction: Feb 20, 2014
Complete Date for F425-D Plan of Correction: Feb 24, 2014
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