Inspection Reports for
Tallgrass Healthcare Campus LLC
1417 W. ASH STREET, JUNCTION CITY, KS, 66441-3332
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
14.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
140% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
81% occupied
Based on a April 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 11, 2019
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-05-24.
Findings
All deficiencies cited in the prior inspection were corrected as of 2019-06-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 11, 2019
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-04-17.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2019-06-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 4
Date: Apr 17, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint investigation #139615 at Valley View Senior Life.
Complaint Details
The inspection was triggered by Complaint #139615 and included a Health Resurvey.
Findings
The facility failed to develop a baseline care plan with specific wound care instructions for a resident with pressure ulcers, failed to provide appropriate care to promote healing and prevent further decline of pressure ulcers, failed to provide an appropriate end date for PRN antipsychotic medications for a resident, and failed to store food in accordance with professional food safety standards.
Deficiencies (4)
F655: The facility failed to develop a baseline care plan for Resident #1 with directions to staff for specific wound care related to pressure ulcers.
F686: The facility failed to provide care to promote healing and prevent further decline of pressure ulcers for Resident #1, resulting in deterioration and new wounds.
F758: The facility failed to provide an appropriate end date for PRN antipsychotic medications Lorazepam and Clonazepam for Resident #51.
F812: The facility failed to store food in accordance with professional standards, including lack of open and received dates on food items and improper drainage pipe installation.
Report Facts
Resident census: 81
Sampled residents: 16
PRN Clonazepam doses administered: 4
Pressure ulcer measurements: 10.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff E | Administrative Nurse | Provided wound updates, measured wounds, and confirmed care plan deficiencies. |
| Administrative Nursing Staff F | Administrative Nurse | Verified care plan issues and prior admission information. |
| Licensed Nursing Staff K | Licensed Nurse | Worked evening shift when resident returned from hospital and did not assess wounds. |
| Dietary Manager BB | Dietary Manager | Verified food storage deficiencies including lack of dates on food items. |
| Administrative Nurse D | Administrative Nurse | Verified PRN medication orders lacked end dates. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 1, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-03-13.
Findings
All deficiencies have been corrected as of the compliance date of 2018-04-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 3, 2018
Visit Reason
A complaint survey was conducted on 5/3/18 for complaint #KS00129112.
Complaint Details
Complaint #KS00129112 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 3, 2018
Visit Reason
A complaint survey was conducted on 2018-05-03 for complaint #KS00129112.
Complaint Details
Complaint #KS00129112 was investigated and found unsubstantiated with no noncompliance.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Mar 29, 2018
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life to address deficiencies cited during a prior survey inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including weight loss monitoring, environmental safety, medication management, food preparation, and sanitation practices. The facility has implemented policies and monitoring systems to ensure compliance and resident safety.
Deficiencies (10)
F0000 Valley View Senior Life has developed and implemented a facility-wide system to assure correction and continued compliance with regulations. The Quality Assurance Committee reviews and acts on the deficiency list.
F580-D The facility will ensure residents with significant weight loss receive assessment and recommendations by the RD, and physicians are notified within 24 hours. Resident #63 was discharged.
F584-E The facility will maintain a safe, clean, and comfortable environment by replacing damaged tablecloths and conducting routine inspections. Preventative maintenance policies have been reviewed and scheduled.
F610-D The Controlled Medication Policy was revised to require fentanyl patches to be covered and location verified each shift. Discrepancies will be investigated and reported.
F689-D The facility repaired a door with a locked lock and self-closing hinges to maintain a safe environment. Doors and chemical storage will be monitored by staff.
F690-D Residents using leg drainage bags will be monitored for skin irritation and output. Staff education on monitoring and notification has been provided.
F692-E The facility implemented a 'poor oral intake' policy with interventions and monitoring for weight loss. Residents will be weighed regularly and referred to RD and physicians as needed.
F758-D All residents receiving anti-psychotic medications have appropriate diagnoses. Resident #128's medical record was adjusted and diagnosis clarified.
F804-E Pureed food preparation will follow recipes reviewed by CDM and RD. Training and compliance monitoring will be provided.
F812-F All food will be prepared, distributed, and served in a sanitary manner. Staff education on hair containment and cleaning schedules have been implemented.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 9
Date: Mar 13, 2018
Visit Reason
Health Resurvey and Complaint Investigations #126303, #126339, #127319 and #125198.
Complaint Details
The inspection was triggered by multiple complaint investigations (#126303, #126339, #127319, #125198).
Findings
The facility failed to notify the physician about significant weight loss for one resident, maintain a safe and clean environment, thoroughly investigate and report a missing narcotic patch, ensure safe environment free of hazards, provide appropriate catheter care, maintain nutritional status for several residents, ensure appropriate use of psychotropic medication, prepare pureed food as per recipe, and maintain sanitary food preparation conditions.
Deficiencies (9)
F580: The facility failed to notify the physician about significant weight loss for Resident #63, placing the resident at risk for continued weight loss and nutritional problems.
F584: The facility failed to ensure a safe, clean, comfortable and homelike environment in the dining room and on 4 of 4 halls for the 76 residents who resided in the facility.
F610: The facility failed to thoroughly investigate and report a missing Fentanyl patch to the state agency for Resident #28, placing the resident at risk for uncontrolled pain and misappropriation of medications.
F689: The facility failed to ensure the environment was free of accessible hazardous chemicals for 4 cognitively impaired, independently mobile residents, placing them at risk for injury.
F690: The facility failed to ensure Resident #78's urinary catheter leg bag strap was placed appropriately and failed to drain the leg bag as directed, resulting in pain and skin breakdown.
F692: The facility failed to provide necessary cares and services to maintain weight and nutritional status for 4 of 11 sampled residents, including Resident #63 with severe weight loss of 25.4 lbs or 15.45% in 30 days.
F758: The facility failed to ensure an appropriate diagnosis for the use of scheduled Risperdal for Resident #128, placing the resident at risk for adverse medication side effects.
F804: The facility failed to prepare pureed food as directed in the recipe for 6 residents, placing each resident at risk for not having nutritional needs met.
F812: The facility failed to prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen, which provides meals for the 76 residents who reside in the facility.
Report Facts
Resident census: 76
Weight loss: 25.4
Weight loss percentage: 15.45
Weight loss: 6.2
Weight loss percentage: 4.5
Weight loss: 11.6
Weight loss percentage: 6.68
Weight loss: 25.2
Weight loss percentage: 14.7
Weight loss: 6.8
Weight loss percentage: 3.9
Weight loss: 13.4
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 13, 2018
Visit Reason
The visit was conducted 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 a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-04-10.
Deficiencies (1)
The facility had a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm without immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 25, 2017
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-201 (a)(b) and 26-41-104 (d) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-201 (a)(b) deficiency was corrected by the revisit date.
Regulation 26-41-104 (d) deficiency was corrected by the revisit date.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 25, 2017
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the deficiencies previously cited under regulation numbers 26-41-201 (a)(b) and 26-41-104 (d) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-201 (a)(b) deficiency was corrected as of 10/25/2017.
Regulation 26-41-104 (d) deficiency was corrected as of 10/25/2017.
Inspection Report
Re-Inspection
Census: 8
Deficiencies: 5
Date: Sep 26, 2017
Visit Reason
Licensure re-survey conducted at an attached assisted living facility to assess compliance with state regulations.
Findings
The facility failed to ensure the functional capacity screening form included all required elements and definitions. Negotiated Service Agreements lacked required collaboration and detail. Health care services were not fully coordinated according to resident needs and agreements. Disaster and emergency preparedness plans were incomplete and not reviewed quarterly with staff and residents.
Deficiencies (5)
Functional Capacity Screen did not include all required elements and definitions as specified by the department for residents #925, #926, and #927.
Negotiated Service Agreements for residents #925 and #926 lacked collaboration with residents or representatives and omitted required service and payment details.
Negotiated Service Agreement for resident #925 was not reviewed or revised at least once every 365 days as required.
Licensed nurse failed to provide or coordinate necessary health care services in accordance with functional capacity screening and negotiated service agreements for residents #925 and #926.
Facility failed to ensure quarterly review of the emergency management plan with employees and residents, and emergency drills did not include evacuation to a secure location.
Report Facts
Census: 8
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse #B | Interviewed regarding functional capacity screening and negotiated service agreements | |
| Administrative Staff #A | Interviewed regarding emergency management plan | |
| Maintenance Supervisor #C | Interviewed regarding fire drill records | |
| Operator #D | Interviewed regarding resident disaster reviews |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 23, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report documents completion of corrective actions for multiple regulatory requirements.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 4
Date: Aug 17, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for facility compliance with Medicare and Medicaid regulations.
Complaint Details
The inspection included complaint investigations #93379 and #86746.
Findings
The facility failed to provide appropriate liability and appeal notices to residents, did not develop comprehensive care plans including use of bed cane/positioning devices for some residents, and failed to ensure the resident environment was free of accident hazards related to bed rails/canes. Additionally, the facility failed to prepare and serve food in a sanitary manner due to improperly secured hairnets worn by dietary staff.
Deficiencies (4)
F156: The facility failed to provide appropriate liability and appeal notices for 3 of 6 residents reviewed, lacking timely notification of Medicare service end dates.
F279: The facility failed to develop comprehensive care plans that included use of bed cane/positioning devices for 2 of 3 residents reviewed.
F323: The facility failed to ensure the resident environment was free of accident and entrapment hazards related to bed rails/canes for 3 residents, with gaps exceeding FDA recommended limits.
F371: The facility failed to prepare and serve food in a sanitary manner due to dietary staff not properly securing hairnets on 2 of 4 days observed.
Report Facts
Resident sample size: 15
Residents with liability notice issues: 3
Residents with care plan deficiencies: 2
Residents with environmental hazards: 3
Hairnet noncompliance days: 2
Bed cane horizontal opening: 11
Bed cane vertical opening: 6.25
Side rail gap width: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 17, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation 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, 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 based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the letter regarding the plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Aug 17, 2016
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations. Specific deficiencies addressed include documentation maintenance, care plan accuracy, environmental safety, and sanitary food preparation.
Deficiencies (5)
F0000: Valley View Senior Life has developed and implemented a facility-wide system to assure correction and continued compliance with regulations. All residents have the potential to be impacted by these deficiencies.
F156-D: The facility will ensure all necessary documentation is signed and maintained in residents' files and notify residents of Medicare benefit discontinuation at least 48 hours prior to service end.
F279-D: Valley View Senior Life will develop and maintain comprehensive care plans accurately reflecting use of bed cane/positioning devices for all residents, with ongoing review for accuracy.
F323-D: The facility will ensure the resident environment remains free of accident hazards by revising the side rail policy to include proper measuring of gaps not exceeding 4.75 inches.
F371-F: All food will be prepared and distributed in a sanitary manner, with dietary staff educated on hair containment using larger hair nets to accommodate various hairstyles.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: May 12, 2016
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life in response to deficiencies cited during a prior complaint-related survey.
Findings
The facility developed and implemented corrective actions addressing deficiencies related to resident mistreatment, neglect, abuse, environmental maintenance, care plan revisions, and accident prevention. Monitoring and oversight responsibilities were assigned to various staff members to ensure ongoing compliance.
Deficiencies (5)
F0000: The facility developed a system to assure correction and continued compliance with regulations for all cited deficiencies. A complete deficiency list was provided to the Quality Assurance Committee for review and action.
F225-D: Policies prohibit mistreatment, neglect, abuse, and misappropriation of resident property. The facility will report all alleged violations to the administrator and officials per Kansas State Statute.
F253-E: The facility will ensure all residents receive housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior. Repairs to ductwork and wall damage were completed during the survey.
F280-D: The facility will revise care plans for residents based on condition changes, hospital readmissions, and unmet outcomes. Fall assessments and intervention adjustments will be ongoing.
F323-D: The facility will maintain a safe environment free of accident hazards and provide supervision to prevent accidents. Care plans were revised and therapy services requested for a resident with falls.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 12, 2016
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 listed with their regulation numbers were corrected by the revisit date of 05/12/2016.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 4
Date: May 4, 2016
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaint investigations related to resident care and facility conditions.
Complaint Details
The inspection was triggered by multiple complaint investigations (#99748, 99005, 98248, 97598, 97146, 97221, 97401, 96559, 96470, 96063, 95179, 93908, 93158, 86629, 99218, 99382, 99511, and 99912).
Findings
The facility failed to report an extensive bruise of unknown origin for a cognitively impaired resident, maintain a sanitary interior, revise care plans to prevent future falls, and provide adequate supervision and effective interventions to prevent falls for a resident with a history of multiple falls.
Deficiencies (4)
F225: The facility failed to report an extensive bruise of unknown origin for a cognitively impaired resident to the state agency within required timeframes.
F253: The facility failed to maintain a sanitary interior, with black substance on ceiling tiles and a hole in a resident's room wall.
F280: The facility failed to revise the care plan with effective interventions to prevent future falls for a resident with severe cognitive impairment and a history of multiple falls.
F323: The facility failed to provide adequate supervision and effective interventions to prevent future falls for a cognitively impaired resident with a history of falls.
Report Facts
Resident census: 83
Bruise size: 7
Bruise size: 10
Bruise size: 1.5
Bruise size: 1.6
Fall frequency: 2
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 4, 2016
Visit Reason
An Abbreviated 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 'E' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.
Deficiencies (1)
The facility had 'E' level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact for questions and signatory of the report. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 14, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' 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)
The facility was cited with deficiencies at an 'F' level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Jul 14, 2016
Provider agreement termination date: Oct 14, 2016
Plan of correction submission timeframe: 10
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 2, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies listed by regulation number were corrected as of 04/20/2015, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency corrections: 15
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 2, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously identified deficiencies were corrected by the facility as of April 20, 2015.
Deficiencies (3)
Regulation 26-40-302 (i)(1)(a)((i)(ii)(iii)(iv)) deficiency was corrected by 04/20/2015.
Regulation 26-40-302 (h) deficiency was corrected by 04/20/2015.
Regulation 26-40-305 (3) deficiency was corrected by 04/20/2015.
Inspection Report
Follow-Up
Deficiencies: 15
Date: Jun 2, 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 were corrected.
Findings
All deficiencies previously cited in the original survey were corrected by 04/20/2015 as documented by the correction completion dates for each regulation cited.
Deficiencies (15)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected by 04/20/2015.
Regulation 483.13(c) was corrected by 04/20/2015.
Regulation 483.20(g)-(i) was corrected by 04/20/2015.
Regulation 483.20(d), 483.20(k)(1) was corrected by 04/20/2015.
Regulation 483.20(d)(3), 483.10(k)(2) was corrected by 04/20/2015.
Regulation 483.25 was corrected by 04/20/2015.
Regulation 483.25(c) was corrected by 04/20/2015.
Regulation 483.25(d) was corrected by 04/20/2015.
Regulation 483.25(h) was corrected by 04/20/2015.
Regulation 483.25(l) was corrected by 04/20/2015.
Regulation 483.30(a) was corrected by 04/20/2015.
Regulation 483.35(d)(1)-(2) was corrected by 04/20/2015.
Regulation 483.35(i) was corrected by 04/20/2015.
Regulation 483.60(a),(b) was corrected by 04/20/2015.
Regulation 483.65 was corrected by 04/20/2015.
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Apr 20, 2015
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life to address deficiencies cited during a prior survey inspection.
Findings
The facility has developed and implemented corrective actions to address multiple deficiencies including call light system maintenance, hydrotherapy unit safety, abuse prevention policies, resident assessments, care planning, nursing staff sufficiency, food safety, medication management, and infection control monitoring.
Deficiencies (19)
F0000: Facility-wide system developed to assure correction and continued compliance with regulations for all cited deficiencies.
F0972-F: Preventative maintenance program updated to include weekly testing of call light system to verify operation.
F1364-F: Hydrotherapy units ensured to have ground-fault circuit interrupters; policy reviewed with staff.
F225-E: Policies prohibit mistreatment, neglect, abuse, and misappropriation of resident property; reporting procedures updated.
F226-E: Facility policy revised to address requirements of the Elder Justice Act.
F278-D: Accurate resident assessments ensured using state-approved review instrument; corrections made and ongoing monitoring planned.
F279-D: Comprehensive care plans developed and maintained reflecting personal preferences and repositioning needs.
F280-D: Care plans revised as indicated by condition changes, hospital readmission, or unmet outcomes; safety assessments for electric lift recliners conducted.
F309-D: Necessary care provided to maintain well-being; dialysis patients monitored for bleeding post-dialysis.
F314-D: Residents without pressure sores monitored to prevent development; care plans revised to include repositioning and family involvement.
F315-D: Residents incontinent of bladder receive appropriate treatment to prevent urinary tract infections; toileting programs implemented.
F323-G: Resident environment maintained free of accident hazards; lift recliner policy and assessments implemented with therapy assistance.
F329-D: Antipsychotic drug use restricted to necessary cases with documented diagnosis; care plans updated to reflect non-pharmacological interventions.
F353-E: Sufficient nursing staff provided to maintain resident well-being; staffing evaluated and monitored with resident feedback.
F364-F: Food temperatures recorded prior to serving; dietary staff educated on food temperature policy.
F371-F: Food stored, prepared, and served under sanitary conditions; sanitizer levels tested and logged; staff educated on storage policies.
F425-D: Pharmaceutical services maintained to meet resident needs; medication delivery and reordering processes improved; staff educated on medication administration.
F441-F: Infection control tracking system being developed to calculate infection control rates.
S0964-F: Call light system monitors to be turned on at all times; call light policy updated and staff educated.
Inspection Report
Enforcement
Deficiencies: 0
Date: Apr 2, 2015
Visit Reason
The inspection was conducted 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 deficiency in the facility to be a 'G' level. Enforcement remedies including denial of payment for new Medicare admissions were imposed due to failure to achieve substantial compliance.
Report Facts
Denial of payment effective date: Jul 2, 2015
Substantial compliance deadline: Oct 2, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkins | Administrator | Facility administrator named in the report header |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions in the letter |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 3
Date: Apr 2, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint numbers.
Complaint Details
The inspection included a complaint investigation with complaint numbers #84028, 84058, 83812, 83721, 82725, 78511, 77225.
Findings
The facility failed to ensure the wireless call system monitors were turned on and tested weekly as required. Additionally, the hydrocollator was not plugged into a ground-fault circuit interrupter (GFCI) as required.
Deficiencies (3)
K.A.R. 26-40-302 (i)(1)(a)(i)(ii)(iii)(iv) Nursing facility support system. The facility failed to ensure the wireless call system monitors were turned on during the day, and the licensed nurse's pager was not functioning.
K.A.R. 26-40-302 (h) Nursing facility support systems. The facility failed to test the wireless call system at least weekly, testing it only once a month.
K.A.R. 23-40-305 (3) Electrical requirements. The facility failed to ensure the hydrocollator was plugged into a ground-fault circuit interrupter (GFCI).
Report Facts
Resident census: 81
Call system testing frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse | Observed near the call system monitor which was turned off; pager was not functioning. | |
| Maintenance Staff | Reported call lights were checked once a month and confirmed hydrocollator was not plugged into a GFCI. | |
| Administrative Staff A | Stated the facility did not turn the call system monitors on during the daytime. |
Inspection Report
Enforcement
Deficiencies: 0
Date: Apr 2, 2015
Visit Reason
The inspection was conducted 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 deficiency to be at a 'G' level. Enforcement remedies including denial of payment for new Medicare admissions effective July 2, 2015, were recommended due to failure to achieve substantial compliance.
Report Facts
Denial of payment effective date: Jul 2, 2015
Substantial compliance deadline: Oct 2, 2015
Civil Money Penalty threshold: 5000
IDR submission deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkins | Administrator | Named as facility administrator in report header |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Joe Ewert | Commissioner | Recipient of Informal Dispute Resolution requests |
| Susan Fout | Regional Manager | Copied on report |
| Audrey Sunderraj | Director | Copied on report |
Inspection Report
Life Safety
Deficiencies: 1
Date: Dec 3, 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.
Deficiencies (1)
The facility was cited with an 'F' level deficiency indicating widespread noncompliance with Life Safety Code requirements, posing potential for more than minimal harm without immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Mar 3, 2015
Provider agreement termination date: Jun 3, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkins | Administrator | Named as facility administrator in the report header. |
| 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 in carbon copy (c: line) as KDADS Commissioner. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Dec 3, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied 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.
Deficiencies (1)
The facility was cited with an "F" level deficiency indicating widespread noncompliance with Life Safety Code requirements, posing potential for more than minimal harm without immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date of denial of payments: Mar 3, 2015
Provider agreement termination date: Jun 3, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkins | Administrator | Named as facility administrator in the report. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Joe Ewert | Commissioner | Copied on the enforcement letter. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 31, 2013
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously reported deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 26-42-102 (d) deficiency identified by code S5258 was corrected by 2013-12-31.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 31, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The report documents that all previously cited deficiencies identified by regulation numbers 483.13(c), 483.20(g)-(j), 483.25(i), 483.25(l), and 483.35(i) were corrected by the revisit date of 12/31/2013.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 31, 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 deficiencies previously cited under various regulations were corrected as of the revisit date. The report confirms completion of corrective actions for each identified deficiency.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 5
Date: Dec 17, 2013
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation #69591 to assess compliance with regulatory requirements.
Complaint Details
The visit was triggered by a complaint investigation #69591. The findings included failure to timely obtain criminal background checks, inaccurate resident assessments, failure to maintain nutritional documentation, failure to follow medication protocols, and unsanitary food handling practices.
Findings
The facility was found deficient in multiple areas including failure to timely obtain criminal background checks for staff, inaccurate resident assessments, failure to maintain nutritional status documentation, failure to ensure drug regimens were free from unnecessary drugs, and failure to maintain sanitary food preparation and serving conditions.
Deficiencies (5)
F226: The facility failed to obtain timely criminal background check results for 1 of 5 staff members hired since the last survey.
F278: The facility failed to accurately assess 1 of 19 sampled residents using the state-approved review instrument, incorrectly documenting pressure ulcers and foot lesions.
F325: The facility failed to monitor and document the intake of physician-ordered protein supplements for 1 of 6 sampled residents to maintain nutritional status.
F329: The facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 5 residents by not following physician-ordered blood sugar parameters and failing to notify the physician of out-of-range results.
F371: The facility failed to prepare, distribute, and serve food under sanitary conditions, including failure to change gloves after contamination and failure to discard contaminated food.
Report Facts
Resident census: 86
Sample size: 19
Staff background check delay: 36
Blood sugar results: 322
Blood sugar results: 312
Blood sugar results: 363
Inspection Report
Re-Inspection
Census: 7
Deficiencies: 1
Date: Dec 17, 2013
Visit Reason
The inspection was a Licensure Resurvey to verify compliance with staff qualifications and employee record requirements.
Findings
The facility failed to conduct timely criminal background checks for newly hired staff, resulting in noncompliance with policies designed to prevent mistreatment, neglect, abuse, and misappropriation of resident property.
Deficiencies (1)
26-42-102 (d) Staff Qualifications Employee Records: The facility failed to conduct criminal record checks for 1 of 1 staff member hired since October 2012 prior to providing care to residents.
Report Facts
Census: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse F | Verified facility policy on criminal background checks for new hires |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 20, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies related to regulations 483.13(c), 483.20(d), 483.10(k), 483.25, and 483.25(h) have been corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Date: Aug 28, 2013
Visit Reason
The inspection was conducted as a result of complaint investigations #67159 and #66631 concerning allegations of abuse, neglect, and failure to provide adequate care.
Complaint Details
The visit was complaint-related based on investigations #67159 and #66631. The complaints involved allegations of abuse, neglect, and failure to report and investigate incidents properly. The facility was found to have substantiated deficiencies related to these complaints.
Findings
The facility failed to thoroughly investigate and report an injury from a coffee spill, failed to review and revise the care plan for a resident, and failed to provide necessary care and services to maintain residents' highest practicable well-being. Additionally, the facility failed to ensure adequate supervision to prevent accidents for one resident.
Deficiencies (4)
F225: The facility failed to thoroughly investigate and report an accident resulting in injury for Resident #2 involving a coffee spill causing burns.
F280: The facility failed to review and revise the plan of care for Resident #2 after the coffee spill incident and burn injury.
F309: The facility failed to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for Residents #1 and #2.
F323: The facility failed to ensure Resident #2 received adequate supervision to prevent accidents, resulting in a burn injury from spilled coffee.
Report Facts
Resident census: 80
Coffee temperature: 164.5
Blood sugar reading: 36
Burn wound size: 1.5
Burn wound size: 0.5
Burn wound size: 0.1
Burn wound size: 13
Burn wound size: 2.5
Burn wound size: 0.1
Burn redness size: 15
Burn redness size: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Interviewed regarding the coffee spill incident, burn evaluation, and supervision of Resident #2. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 5, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies under regulations 483.15(a), 483.15(h)(2), 483.25(h), and 483.65 were corrected by the revisit date of 11/5/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 5, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.15(a), 483.15(h)(2), 483.25(h), and 483.65 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Oct 9, 2012
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations. Deficiencies included issues with resident dignity, housekeeping and maintenance, accident hazards, and infection control.
Deficiencies (4)
F241-D: The facility failed to maintain or enhance each resident's dignity and respect. Employees will be educated on maintaining dignity during dining and care.
F253-E: The facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior. Repairs and replacements of various facility components were initiated.
F323-D: The facility failed to ensure the resident environment was free of accident hazards. Nursing staff will be educated on following care plans and having necessary care items available.
F441-D: The facility failed to establish and maintain an effective Infection Control Program. Nursing staff will be re-educated on respiratory therapy infection prevention policies and proper handling of oxygen and C-PAP equipment.
Report Facts
Items completed: 8
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 4
Date: Oct 8, 2012
Visit Reason
The inspection was conducted as a health facility resurvey and complaint investigations #60127 and #60229 at Valley View Senior Life.
Complaint Details
The inspection included complaint investigations #60127 and #60229. The complaints involved failure to provide dignity and respect, unsafe environment, and infection control issues. The findings substantiated these complaints.
Findings
The facility failed to provide dignity and respect to residents during toileting and dining, failed to maintain housekeeping and maintenance services resulting in unsanitary and unsafe conditions on multiple halls, failed to provide an environment free of accident hazards for a resident with a history of falls, and failed to maintain infection control practices related to oxygen therapy equipment.
Deficiencies (4)
F241: The facility failed to provide dignity and respect to Resident #14 and another resident by not ensuring privacy during toileting and by staff making inappropriate comments and facial expressions during dining.
F253: The facility failed to maintain housekeeping and maintenance services necessary to keep the interior sanitary, orderly, and in good repair on 3 of 4 halls, including stained fixtures, damaged walls, and running toilets.
F323: The facility failed to provide an environment free of accident hazards for Resident #14 by leaving the resident unattended on the toilet despite a history of falls and noncompliance with waiting for staff assistance.
F441: The facility failed to maintain infection control by not properly storing oxygen therapy equipment, leading to contamination risks for residents using oxygen on 2 of 4 halls.
Report Facts
Census: 87
Sample size: 29
Non-injury falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Verified staff should provide privacy during toileting and stay with resident while in bathroom; verified staff did not provide dignity and respect. | |
| Nurse Assistant H | Observed making inappropriate comments and facial expressions toward residents during dining. | |
| Dietary Staff I | Verified staff should not make faces at residents or refer to feeding residents as feeding. | |
| Nurse A | Observed leaving Resident #14 alone on the toilet without assistance. | |
| Nurse Assistant B | Verified resident should not be left alone on the toilet and staff should watch for unsafe toileting attempts. | |
| Nurse I | Verified C-PAP tubing and mask were contaminated if lying on floor or bedside table and should be stored properly. | |
| Maintenance Staff E | Verified maintenance deficiencies during environmental tour. | |
| Maintenance Staff F | Verified maintenance deficiencies during environmental tour. | |
| Administrative Staff G | Verified maintenance deficiencies during environmental tour. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N031003 POC 83OB11
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented a system to assure correction and compliance with regulations, addressing issues including mistreatment, neglect, abuse, assessment accuracy, nutritional status, medication regimen, and sanitary food service.
Deficiencies (6)
F0000: The facility developed and implemented a system to assure correction and continued compliance with regulations affecting all residents.
F226-D: The facility will implement policies prohibiting mistreatment, neglect, abuse, and misappropriation of residents' property, with criminal background checks for employees.
F278-D: The facility will use a state-approved review instrument to provide accurate assessments of all residents and monitor accuracy ongoing.
F325-D: The facility will ensure nutritional status parameters are determined and physician-ordered supplements are recorded in residents' records.
F329-D: The facility will ensure residents' regimens are free from unnecessary medications and educate nursing staff on following physician orders for blood sugar notifications.
F371-F: The facility will store, prepare, and serve food under sanitary conditions, educating dietary staff on glove usage and discarding contaminated items to prevent cross-contamination.
Report Facts
Complete Date: Dec 31, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkens | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N031003 POC 8JYF11
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations. Policies prohibiting mistreatment, neglect, abuse, and misappropriation of residents' property are being developed and implemented, with employee background checks monitored by Human Resources and the Administrator.
Deficiencies (2)
For the deficiencies cited during the survey, Valley View Senior Life has developed and implemented a facility-wide system to assure correction and continued compliance with regulations.
Valley View Senior Life will continue to develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of residents' property, with criminal background checks required prior to employment.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkens | Administrator | Submitted the Plan of Correction. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N031003 POC DD3E11
Visit Reason
This document serves as a Plan of Correction related to a prior deficiency report for the facility.
Findings
No specific findings are detailed in this document; it references a linked deficiency report but contains no records or findings itself.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N031003 POC YWDG11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N031003 POC DD3E12
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: N031003 POC E2NJ11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint survey at Valley View Senior Life.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations related to mistreatment, neglect, abuse, care planning, documentation, and resident safety.
Deficiencies (5)
F0000: The facility developed a system to assure correction and continued compliance with regulations for deficiencies cited during the complaint survey. All residents have the potential to be impacted.
F225-D: The facility will ensure all alleged violations involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator and other officials as required by state law.
F280-D: The facility must use assessment results to develop, review, and revise residents' comprehensive plans of care to accurately reflect individual needs and safety.
F309-D: The facility will ensure residents receive necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being according to assessments and plans of care.
F323-D: The facility will ensure the resident environment is free of accidents and hazards and provide adequate supervision and assistive devices to prevent accidents, including safety assessments related to the public coffee pot.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: N031003 POC FHIK11
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life to address deficiencies cited during a prior survey.
Findings
The facility identified multiple deficiencies including failure to develop baseline care plans within 48 hours, inadequate pressure relieving devices and wound care instructions, lack of stop dates on anti-anxiety medication orders, and improper food storage and safety procedures. Corrective actions and ongoing monitoring plans were implemented for each deficiency.
Deficiencies (5)
F0000: Facility developed and implemented a system to assure correction and continued compliance with cited deficiencies. All residents have potential to be impacted.
F655-D: Baseline Care Plans will be developed within 48 hours for all new residents and closed upon discharge. Careplan team members have been educated on the process.
F686-G: All residents will have appropriate pressure relieving devices and staff will receive wound care instructions. Communication during resident transfers will be improved.
F785-D: All residents receiving anti-anxiety medications will have a stop date assigned prior to initiation. Medical records have been updated accordingly.
F812-F: Food will be stored, prepared, distributed, and served according to professional food safety standards. Drain pipe repaired and dietary staff trained on proper food storage procedures.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N031003 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection event for facility State ID N031003 ASPEN.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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