Inspection Reports for
Garden Valley Retirement Village
1505 E SPRUCE STREET, GARDEN CITY, KS, 67846-6296
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
12.9 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
115% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
73% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 45
Deficiencies: 7
Date: Jun 12, 2025
Visit Reason
Routine inspection of Garden Valley Retirement Village to assess compliance with regulatory requirements related to resident care, safety, medication administration, and dietary services.
Findings
The facility was found deficient in multiple areas including discharge planning, maintenance of residents' functional abilities, provision of personal care, fall prevention interventions, PICC line care, medication regimen review, and preparation of pureed diets. These deficiencies placed residents at risk for unmet care needs, decreased independence, impaired dignity, falls, infection, unnecessary medication use, and poor nutrition.
Deficiencies (7)
F 0627: The facility failed to ensure discharge needs were identified and an appropriate discharge plan was created for Resident 39, risking unmet care needs and inappropriate discharge.
F 0676: The facility failed to ensure Resident 43 received services to maintain activities of daily living, risking decreased functional abilities and independence.
F 0677: The facility failed to provide adequate ADL care including grooming of facial hair for Resident 45, risking impaired dignity and poor hygiene.
F 0689: The facility failed to ensure an environment free from accident hazards and adequate supervision to prevent falls for Resident 38, who had multiple falls.
F 0694: The facility failed to provide adequate care for Resident 41's PICC line, including timely dressing changes and proper labeling of IV antibiotic medication, risking complications.
F 0756: The facility failed to implement provider orders based on the consultant pharmacist's monthly medication review for Resident 38, risking unnecessary medication use.
F 0804: The facility failed to provide food prepared according to recipes for pureed diets, risking impaired nutrition and diminished meal enjoyment for residents.
Report Facts
Residents present: 45
Residents sampled: 12
Days late for PICC dressing change: 2
Venlafaxine dose: 150
Venlafaxine dose: 75
Venlafaxine dose: 100
Pureed diet residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Reported on PICC line dressing, medication regimen review, and fall interventions |
| Social Service X | Social Service | Responsible for discharge planning and social service notes for Resident 39 |
| Licensed Nurse H | Licensed Nurse | Reported on PICC line medication administration and dressing |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on Resident 38's confusion and fall risk |
| Therapy Staff JJ | Therapy Staff | Reported on therapy services and resident ambulation |
| Therapy Staff HH | Therapy Staff | Reported on therapy evaluations and resident ambulation |
| Business Office Manager KK | Business Office Manager | Reported on therapy co-pay refusal documentation |
| Dietary Staff BB | Dietary Staff | Reported lack of pureed diet recipes and preparation practices |
| Dietary Staff EE | Dietary Staff | Reported lack of pureed diet recipes and preparation practices |
| Dietary Staff FF | Dietary Staff | Reported lack of pureed diet recipes and preparation practices |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 6
Date: Jun 29, 2023
Visit Reason
The inspection was conducted as part of an annual survey of Garden Valley Retirement Village to assess compliance with regulatory requirements and resident care standards.
Findings
The facility failed to accurately complete assessments and care plans for several residents, including failure to identify poor dentition and provide dental services for Resident 41, failure to develop care plans for indwelling urinary catheter care for Resident 7, and failure to revise care plans for compression stockings for Resident 8. Additionally, the facility failed to adequately monitor medications with black box warnings for multiple residents, placing them at risk for adverse effects.
Deficiencies (6)
F641: The facility failed to accurately complete the Minimum Data Set for Resident 41 by not identifying poor dentition, placing the resident at risk for uncommunicated care needs.
F656: The facility failed to develop and implement a comprehensive care plan for Resident 41's dental needs and Resident 7's indwelling urinary catheter care, risking inappropriate care and treatment.
F657: The facility failed to revise Resident 8's care plan related to physician-ordered compression stockings used for edema.
F757: The facility failed to ensure adequate monitoring of black box warning medications for Residents 13 and 29, risking adverse effects.
F758: The facility failed to monitor psychotropic medications with black box warnings for Residents 13, 17, 28, and 29, placing them at risk for adverse effects.
F791: The facility failed to provide dental services or access to dental services for Resident 41 due to widespread dental decay, risking further deterioration of dentition.
Report Facts
Census: 53
Residents reviewed: 13
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Acknowledged inaccurate assessments and MDS data; confirmed expectations for nurse familiarity with black box warnings; verified care plan deficiencies | |
| Licensed Nurse I | Reported lack of knowledge about black box warnings and monitoring requirements | |
| Certified Nurse Aide G | CNA | Reported helping Resident 41 with oral care |
| Certified Nurse Aide H | CNA | Reported never helping Resident 41 with oral care |
| Licensed Nurse K | Reported charge nurses did not update care plans; stated Director of Nursing updated care plans | |
| Social Services J | Denied knowledge of any upcoming dentist appointment for Resident 41 |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 6
Date: Aug 19, 2021
Visit Reason
The inspection was conducted as an annual survey of Garden Valley Retirement Village to assess compliance with regulatory requirements related to resident rights, bed-hold policies, resident assessments, dental services, adaptive eating utensils, and medical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to serve a resident in a timely manner during a meal, failure to provide bed-hold policy notifications upon hospital transfers, inaccurate resident dental status documentation, failure to assist a resident with broken dentures, failure to provide adaptive eating utensils, and failure to maintain complete and timely scanned medical records.
Deficiencies (6)
F 0550: The facility failed to provide Resident 42 with the right to a dignified existence by failing to serve her meal in a timely manner during the noon meal on 08/16/21.
F 0625: The facility failed to provide Residents 28, 42, and 150 or their representatives with a bed-hold policy upon transfer to a hospital, and the policy lacked details on payment obligations.
F 0641: The facility failed to accurately document Resident 35's dental status by not recording her broken dentures.
F 0791: The facility failed to provide Resident 35 with assistance to repair her broken dentures identified over two months prior.
F 0810: The facility failed to provide Resident 46 with adaptive eating utensils and/or plate to improve his ability to eat independently.
F 0842: The facility failed to maintain complete, accurate, and readily accessible medical records by not scanning resident information into the electronic health record in a timely manner.
Report Facts
Residents sampled: 16
Facility census: 50
Bed hold days for Medicaid residents: 10
Bed hold days for skilled residents: 3
Broken teeth on dentures: 2
Built up silverware utensils: 2
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 18, 2015
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at Garden Valley Retirement Village.
Findings
The report documents that the previously cited deficiency with regulation number 26-40-305 (3) was corrected as of 05/23/2015. No other deficiencies are listed.
Deficiencies (1)
Regulation 26-40-305 (3) deficiency was corrected on 05/23/2015.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 18, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as of the dates indicated.
Findings
The report confirms that all previously identified deficiencies listed on the CMS-2567 have been corrected by the facility as of May 23, 2015.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: 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 compliance with state and federal regulations.
Findings
The Plan of Correction details multiple deficiencies related to wound care, resident dignity, bathing preferences, facility maintenance, pain management, therapy services, pressure ulcer prevention, fall investigations, infection control, and equipment safety. The facility commits to systemic changes, staff education, monitoring, and ongoing quality assurance to correct these issues.
Deficiencies (12)
F157-D: Resident #101's physician will be consulted concerning significant changes to pressure ulcers on both heels. The facility will update physicians and families weekly on wound conditions.
F241-D: Staff will be educated to enhance resident #97's dignity by responding promptly to calls and revising care plans for residents with similar needs. Compliance will be monitored by management.
F242-D: Resident #22's bathing preferences were updated and care plans revised. All residents' bathing choices and code status will be reviewed and documented to prevent recurrence.
F253-E: Facility maintenance and housekeeping will address identified repair and cleaning issues. Preventative maintenance logs will be monitored monthly to sustain compliance.
F280-D: Resident #101's wound care plan was reviewed and revised. Weekly interdisciplinary reviews will ensure care plans reflect current treatments for all residents receiving wound care.
F309-G: The facility will monitor resident #112's pain and provide a Spanish-speaking staff member for resident #75's dialysis translation needs. Pain management and dialysis refusals will be addressed systematically.
F311-D: Resident #101 resumed therapy services. Weekly reviews of therapy discharges will monitor referrals to restorative services to prevent lapses in care.
F314-G: Care plans for residents #70 and #101 will be updated with preventative measures for pressure ulcers. High-risk residents will have care plans reviewed quarterly with weekly skin assessments for those with ulcers.
F323-G: Resident #112's fall was investigated with root cause analysis. Fall risk assessments and care plan updates will be conducted for residents with recent falls to prevent future incidents.
F371-F: An appropriate air gap was installed for the skilled nursing unit ice maker. Future installations will include air gaps, monitored by the Maintenance Director.
F441-F: Staff received in-service training on infection control, including linen handling, dressing barriers, and disposal of infectious bandages. Compliance will be monitored weekly with disciplinary actions for noncompliance.
S1364-F: The hydrocollator outlet was replaced with a GFCI outlet. Maintenance will ensure all equipment requiring GFCI outlets are properly installed and monitored monthly.
Inspection Report
Enforcement
Deficiencies: 0
Date: 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. Enforcement remedies including denial of payment for new Medicare admissions effective July 23, 2015, were imposed due to failure to achieve substantial compliance.
Report Facts
Denial of payment effective date: Jul 23, 2015
Substantial compliance deadline: Oct 23, 2015
Civil Money Penalty threshold: 5000
IDR submission deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Stephenson | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Joe Ewert | Commissioner | Recipient of Informal Dispute Resolution requests |
| Teresa Fortney | Regional Manager | Copied on correspondence |
| Audrey Sunderraj | Director | Copied on correspondence |
Inspection Report
Census: 73
Deficiencies: 1
Date: Apr 16, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with state regulations.
Findings
The facility failed to ensure electrical safety in the rehabilitation room by not installing a required ground-fault circuit interrupter (GFCI) outlet for the hydrocollator equipment, creating a potential accident hazard.
Deficiencies (1)
26-40-305 (3) P E - Electrical requirements: The facility failed to install a ground-fault circuit interrupter outlet for the hydrocollator in the rehabilitation room, posing an electrical hazard.
Report Facts
Census: 73
Inspection Report
Life Safety
Deficiencies: 1
Date: 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 a most serious deficiency classified as 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.
Deficiencies (1)
The facility was found to have an 'F' level deficiency in Life Safety Code compliance, indicating widespread issues with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Dec 4, 2014
Provider agreement termination date: Mar 4, 2015
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 24, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-02-10.
Findings
The report confirms that the previously identified deficiency related to regulation 483.60(a),(b) was corrected as of 2014-02-24. No other deficiencies or issues were noted.
Deficiencies (1)
Regulation 483.60(a),(b) deficiency was corrected by the revisit date of 2014-02-24.
Report Facts
Deficiency correction date: Feb 24, 2014
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Feb 20, 2014
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates when corrective actions were accomplished.
Findings
The report confirms that deficiencies identified in prior inspections have been corrected as of the revisit date. Specific regulation numbers and correction completion dates are listed for each deficiency.
Deficiencies (2)
Regulation 26-40-302 (6)(a)(b): Previously cited deficiency corrected as of 02/20/2014.
Regulation 26-40-303 (8)(a)(i)(ii)(iii)(iv)(v): Previously cited deficiency corrected as of 02/20/2014.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 20, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory requirements.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Feb 20, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address 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, infection control, safety measures, and staff education. The facility commits to audits and ongoing monitoring to ensure compliance.
Deficiencies (12)
F0000: The facility alleges substantial compliance with Federal Medicare and Medicaid requirements and will provide the deficiency list to the Quality Assurance Committee for review.
F244-E: The facility will address resident grievances and concerns through resident council meetings and IDT meetings, ensuring all residents have the opportunity to voice concerns.
F278-D: Assessments will accurately reflect resident status; bowel and bladder programs will be redone and care plans updated for specified residents.
F279-D: Care plans will be updated to reflect urinary incontinence management and resident activity preferences, with audits to ensure compliance.
F280-D: Resident 67's care plan was updated to include use of dycem in wheelchair to prevent falls; nursing staff will review incidents and update care plans accordingly.
F311-D: Resident 89's bathing preferences were interviewed and bathing schedule updated; staff documentation will be reviewed to ensure compliance.
F315-D: Direct Care Staff J was educated on infection control techniques; all direct care staff will be educated and monitored for compliance.
F323-E: Maintenance fixed door locking mechanism; a secured cabinet will be provided for resident 10 to store laundry soap; safety audits will be conducted weekly.
F371-F: Dietary staff educated on sanitary serving techniques; new equipment added; staff will be monitored for compliance.
F441-E: Licensed staff educated on infection control techniques including use of barriers and gloves; ongoing monitoring will be conducted.
S0894-E: Linen and trash containers in soiled utility room will be covered with tight fitting lids; staff will be in-serviced and monitoring conducted weekly.
S1146-E: Linen container in soiled laundry room will be covered with tight fitting lid; laundry staff will be in-serviced and monitoring conducted weekly.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: Feb 10, 2014
Visit Reason
The inspection was conducted as an abbreviated survey for complaint investigation #KS00072076 regarding pharmaceutical services.
Complaint Details
The visit was triggered by complaint investigation #KS00072076. The complaint was substantiated as the facility failed to provide timely pain medication and other ordered drugs to resident #4.
Findings
The facility failed to obtain and provide routine medications, including pain medication Norco and Lipitor, to one resident as ordered by the physician, resulting in the resident experiencing unmanaged pain for approximately 18 hours after admission.
Deficiencies (1)
F425 Pharmaceutical services were deficient as the facility failed to obtain and provide routine drugs to resident #4 as ordered by the physician, causing a delay in pain medication administration and missed doses of Lipitor.
Report Facts
Resident census: 73
Residents sampled: 4
Hours delay: 18
Days missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Staff | Confirmed nurse failed to process medication orders and obtain medications |
| Staff B | Direct Care Staff | Administered medications and confirmed awareness of medication order failure |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Date: Jan 22, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #70860 to assess compliance with facility regulations.
Complaint Details
The visit was triggered by a complaint investigation #70860. The findings confirmed issues with soiled linen and trash handling.
Findings
The facility failed to properly cover soiled linen and trash receptacles on multiple days and did not provide policies for trash and linen handling. Observations revealed uncovered trash receptacles and soiled linen containers in utility and laundry areas.
Deficiencies (2)
26-40-302 (6)(a)(b) Soiled Workroom: The facility failed to properly cover soiled linen and trash receptacles on 2 of 4 days during the survey, with lids not fitting tightly and linens uncovered.
26-40-303 (8)(a)(i)(ii)(iii)(iv)(v) Laundry Service: The facility failed to properly cover soiled linen in the laundry receiving area, with open barrels and lids hanging above receptacles.
Report Facts
Census: 70
Sample residents: 16
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
Re-Inspection
Deficiencies: 2
Date: Dec 4, 2012
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies from the survey completed on 2012-10-10.
Findings
The report documents that deficiencies previously reported under regulations 26-40-303 (k)(l)(m)(n) and 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) were corrected as of 2012-11-02.
Deficiencies (2)
Regulation 26-40-303 (k)(l)(m)(n): Previously cited deficiency was corrected by 2012-11-02.
Regulation 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv): Previously cited deficiency was corrected by 2012-11-02.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 4, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated in the facility's plan of correction.
Findings
All deficiencies previously reported on the CMS-2567 were found to be corrected by the revisit date of 11/02/2012, with no uncorrected deficiencies noted.
Report Facts
Deficiency corrections: 12
Inspection Report
Census: 73
Deficiencies: 2
Date: 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 ice machine accessibility and call light system functionality.
Findings
The facility failed to ensure that the ice machine dispensed ice directly into a container and was accessible for self-serve without contamination risk. Additionally, the call light system was found to be malfunctioning, with visual signals not functioning properly for a sampled resident and call light indicators in soiled utility rooms failing to produce audible or visual alerts.
Deficiencies (2)
26-40-303 (k)(l)(m)(n) P E - Dietary area: The ice machine accessible to residents did not dispense ice directly into a container, requiring staff to scoop ice manually, contrary to policy.
26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) P E - Nursing facility support system: The call light system failed to produce a visual signal at the nurses' station for a resident and did not provide functional visual or audible signals in two soiled utility rooms.
Report Facts
Resident census: 73
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Oct 4, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address 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 rights notification, completion of care assessments and care plans, hospice coordination, restorative nursing compliance, water temperature safety, medication management including black box warnings, staffing adequacy, food safety and sanitation, ice machine use, and call system functionality.
Deficiencies (13)
F156-D: The facility must inform residents orally and in writing of their rights and rules, notify residents/legal representatives of demand bill rights when payer source changes, and post Medicaid fraud control unit information.
F272-E: Care assessment summaries and comprehensive nursing care plans must be completed timely for residents, with audits and education provided to ensure compliance.
F274-D: Comprehensive assessments and care plans must include hospice services coordination, with monthly audits to ensure compliance.
F278-D: Resident MDS assessments and care plans must accurately reflect skin conditions such as pressure ulcers, with monthly audits and education provided.
F311-D: Care assessment summaries and restorative nursing programs must be reviewed and updated to reflect residents' current status, with staff education and audits.
F323-K: Water temperatures in resident-use areas must be maintained between 98 and 120 degrees Fahrenheit, with installation of check valves and regular monitoring.
F329-E: Medication care plans must include black box warnings and side effects, with pharmacist reviews and monthly audits to ensure proper documentation.
F353-F: The facility must employ sufficient certified or licensed staff to meet residents' needs, with daily QA rounds and staffing pattern reviews.
F371-F: Food must be procured from approved sources and served under sanitary conditions, with regular audits and staff infection control training.
F465-E: The facility must provide a safe, sanitary, and comfortable environment, including weekly cleaning of refrigerators monitored by nursing and dietary staff.
F497-F: Nurse aides must receive at least 12 hours of in-service training annually, with auditing tools created and reviewed quarterly.
S1144-E: Ice machines must dispense ice directly into containers and be designed to minimize noise and spillage; non-compliant machines must be locked and monitored weekly.
S1164-E: The facility must have a functional call system ensuring immediate notification of nursing personnel when residents activate calls, with monthly checks and quarterly reviews.
Report Facts
Date of water temperature check: Oct 4, 2012
Date of ice machine lock: Oct 20, 2012
Date of call light repair: Oct 10, 2012
Minimum nurse aide training hours: 12
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Sep 15, 2012
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at the facility.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Garden Valley 081712 Complaint.
Findings
The facility submitted corrective actions addressing deficiencies related to resident privacy, accident hazard prevention, and infection control practices. The plan includes staff education, monitoring, and audits to ensure compliance.
Deficiencies (3)
F164: The facility failed to provide personal privacy and confidentiality during personal care, including toilet use. Staff will be educated on privacy practices such as closing doors and using curtains, with monitoring by administration.
F323: The facility failed to ensure a safe environment by inadequate supervision and assistive device use to prevent accidents. Care plans and staff education on gait belt use and alarm appropriateness will be implemented and monitored.
F441: The facility failed to maintain infection control by not properly disinfecting showers and whirlpools and inconsistent hand hygiene. Staff will be educated and monitored through audits until proficiency is achieved.
Report Facts
Completion date: Sep 15, 2012
Audit frequency: 3
Audit frequency: 1
Inspection Report
Follow-Up
Deficiencies: 3
Date: Sep 15, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report shows that all previously reported deficiencies identified by regulation numbers 483.10(e), 483.75(l)(4), 483.25(h), and 483.65 were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.10(e), 483.75(l)(4): Previously cited deficiency corrected as of 09/15/2012.
Regulation 483.25(h): Previously cited deficiency corrected as of 09/15/2012.
Regulation 483.65: Previously cited deficiency corrected as of 09/15/2012.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 14, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report for the facility Garden Valley.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Date: Aug 17, 2012
Visit Reason
The inspection was an abbreviated survey conducted in response to complaint #KS 00059037.
Complaint Details
The complaint investigation was triggered by complaint #KS 00059037. The findings included failures in resident privacy, fall prevention, and infection control.
Findings
The facility failed to provide personal privacy for residents, ensure adequate supervision and use of assistive devices to prevent falls, and maintain effective infection control practices including proper sanitization of shower equipment and hand hygiene.
Deficiencies (3)
F 164: The facility failed to provide personal privacy for residents #108 and #103 when staff opened the resident's room door while the resident was in the bathroom with the door open, exposing them to staff, residents, and public view.
F 323: The facility failed to ensure resident #108 received adequate supervision and assistive devices to prevent accidents when staff failed to use a gait belt during transfers and failed to use a chair alarm as directed by the care plan.
F 441: The facility failed to maintain infection control by not effectively sanitizing shower equipment between residents and by staff failing to wash hands or change gloves appropriately after resident contact, risking disease transmission.
Report Facts
Census: 70
Residents sampled: 7
Residents sampled for privacy: 4
Residents sampled for falls: 4
Fall Risk score: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff G | Provided statements regarding expectations for privacy, use of gait belts, chair alarms, and hand hygiene. | |
| Administrative nursing staff B | Provided statements regarding staff expectations for privacy, use of gait belts, chair alarms, and hand hygiene. | |
| Direct care staff J | Observed transferring resident #108 without gait belt and involved in privacy violation. | |
| Direct care staff K | Observed transferring resident #108 without gait belt and involved in privacy violation. | |
| Direct care staff M | Observed transferring resident #108 with gait belt but failed to place chair alarm as directed. | |
| Direct care staff C | Observed improper sanitization of shower equipment by rinsing disinfectant immediately. | |
| Direct care staff L | Observed improper sanitization of shower equipment and failure to scrub surfaces as per instructions. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 31, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the plan of correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.25, 483.25(a)(2), and 483.25(l) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 5, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Garden Valley 070512 Complaint.
Findings
The facility submitted corrective actions addressing deficiencies related to pain management, therapy services, restorative nursing programs, and medication regimen monitoring to ensure compliance with Federal Medicare and Medicaid requirements.
Deficiencies (3)
F309-D: The facility must assure each resident receives necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being according to the comprehensive assessment and plan of care.
F311-E: The facility must assure each resident is offered appropriate treatment and services to maintain or improve abilities.
F329-D: The facility must assure each resident's drug regimen is free from unnecessary drugs.
Report Facts
Complete Date: Jul 31, 2012
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Date: Jul 5, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on allegations identified by Complaint Investigations #KS00056899 and #KS00058112.
Complaint Details
The inspection was triggered by complaints regarding inadequate pain management and medication monitoring, as well as failure to provide appropriate restorative nursing services.
Findings
The facility failed to provide necessary care and services to maintain residents' highest well-being, including pain management for Resident #5 and restorative nursing services for Residents #1, #2, #3, and #4. Additionally, the facility failed to monitor and manage unnecessary medications causing excessive drowsiness in Resident #5.
Deficiencies (3)
F309: The facility failed to provide Resident #5 with adequate pain assessment and management, ignoring verbal and nonverbal pain cues during care.
F311: The facility failed to provide appropriate restorative nursing services to maintain or improve ADL abilities for Residents #1, #2, #3, and #4, despite documented declines and therapy recommendations.
F329: The facility failed to monitor Resident #5 for adverse effects of multiple medications causing excessive drowsiness and did not adjust medication accordingly.
Report Facts
Census: 67
Residents sampled: 9
Residents reviewed for pain issues: 3
Residents reviewed for restorative nursing: 4
Medication administration dates: 30
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 18, 2011
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
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.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 6
Date: Jul 19, 2011
Visit Reason
The inspection was a health resurvey and complaint investigation of Garden Valley Retirement Village.
Complaint Details
The inspection was triggered by a complaint investigation #49137.
Findings
The facility failed to conduct comprehensive assessments, develop appropriate care plans, provide necessary care for skin and incontinence issues, maintain sanitary food preparation conditions, and ensure timely medication administration.
Deficiencies (6)
F272: The facility failed to conduct initial and periodic comprehensive and accurate assessments for 3 of 19 sampled residents related to incontinence and skin conditions.
F279: The facility failed to develop comprehensive care plans for 2 of 19 residents related to incontinence and skin problems.
F309: The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for 2 of 3 residents with non-pressure related skin conditions.
F315: The facility failed to ensure that 2 of 3 residents with incontinence received appropriate treatment and services to restore as much normal bladder function as possible.
F371: The facility failed to store and prepare food under sanitary conditions in two kitchens, including undated food items, dirty equipment, and improper sanitizer levels.
F425: The facility failed to provide medication to one resident as ordered by the physician in a timely manner due to medication being left in a backup drawer for six days.
Report Facts
Resident census: 65
Incontinent episodes: 10
Incontinent episodes: 5
Medication administration days missed: 6
Skin tear size: 3
Skin tear size: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Confirmed lack of toileting plan for resident #97 and medication delay for resident #55 |
| Licensed Nurse C | Licensed Nurse | Confirmed computer-generated check marks without further assessments and lack of care plan for resident #97 and #28 |
| Licensed Nurse J | Licensed Nurse | Unaware of skin tear on resident #28 and resident #28's toileting needs |
| Licensed Nurse K | Licensed Nurse | Confirmed lack of care plan related to resident #97's incontinence |
| Licensed Nurse L | Licensed Nurse | Changed dressing for resident #102's wound but confirmed lack of care plan and treatment instructions |
| Dietary Staff N | Dietary Staff | Acknowledged sanitizer checks were not done correctly and deep fat fryer cleaning schedule missing |
| Dietary Staff O | Dietary Staff | Unaware of cleaning responsibility for standing fan in kitchen |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N028002 POC U5OP11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as U5OP11 for the facility with State ID N028002.
Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the related deficiency report but states no records found.
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