Inspection Reports for Tallgrass Healthcare Campus LLC
1417 W. ASH STREET, KS, 66441-3332
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 1, 2018, found no deficiencies and confirmed the facility was in compliance with all regulations surveyed. Earlier inspections showed a pattern of deficiencies mainly related to resident care issues such as weight loss monitoring, medication management, and food preparation sanitation, as well as environmental safety concerns including hazardous chemical storage and accident hazards. Complaint investigations were generally unsubstantiated, with no enforcement actions or fines listed in the available reports. Prior surveys included plans of correction that addressed these areas, and follow-up inspections verified that previously cited deficiencies were corrected. This indicates improvement over time, with the facility achieving compliance in its most recent review.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
15.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
76 residents
Based on a March 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
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 cited in the previous inspection have been corrected as of the compliance date 2018-04-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 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 not substantiated.
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
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.
Report Facts
Complaint number: 129112
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Mar 29, 2018
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life in response to 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. The facility has implemented policies and monitoring systems to ensure compliance and resident safety.
Deficiencies (9)
Failure to monitor and address significant weight loss in residents
Failure to maintain a safe, clean, and comfortable environment including replacement of damaged tablecloths
Inadequate controlled medication policy regarding fentanyl patch management
Unsafe environment due to door hazards and improper chemical storage
Inadequate monitoring of residents using leg drainage bags for skin irritation
Failure to timely identify and treat weight loss and poor oral intake
Inappropriate use of anti-psychotic medication without proper diagnosis
Failure to prepare pureed food as directed by recipe
Failure to ensure all food is prepared, distributed, and served in a sanitary manner
Report Facts
Complete Date for Deficiency F0000: Mar 29, 2018
Complete Date for Deficiency F580-D: Apr 10, 2018
Complete Date for Deficiency F584-E: Apr 10, 2018
Complete Date for Deficiency F610-D: Mar 29, 2018
Complete Date for Deficiency F689-D: Mar 29, 2018
Complete Date for Deficiency F690-D: Mar 29, 2018
Complete Date for Deficiency F692-E: Mar 29, 2018
Complete Date for Deficiency F758-D: Mar 29, 2018
Complete Date for Deficiency F804-E: Mar 29, 2018
Complete Date for Deficiency F812-F: Mar 29, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkens | Administrator | Administrator submitting the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 13, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at level 'F', 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 reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-04-10.
Deficiencies (1)
Most serious deficiency at level 'F', widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Contact person for the survey and plan of correction acceptance. |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 9
Date: Mar 13, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations for multiple complaint numbers.
Findings
The facility had multiple deficiencies including failure to notify physicians of significant weight loss, unsafe and unclean environment, failure to investigate and report missing narcotic medication, unsafe environment with accessible hazardous chemicals, inadequate catheter care, failure to maintain nutritional status, inappropriate use of psychotropic medications, failure to prepare pureed food as per recipe, and unsanitary food preparation and serving conditions.
Deficiencies (9)
Failed to notify physician about significant weight loss for Resident #63.
Failed to ensure a safe, clean, comfortable, homelike environment in dining room and on 4 halls.
Failed to thoroughly investigate and report missing Fentanyl patch for Resident #28.
Failed to ensure environment free of accessible hazardous chemicals for 4 cognitively impaired, independently mobile residents.
Failed to provide appropriate catheter care and drainage for Resident #78 resulting in pain and skin breakdown.
Failed to maintain nutritional status and implement interventions for 4 residents including Resident #63 with severe weight loss.
Failed to ensure appropriate diagnosis for scheduled antipsychotic medication for Resident #128.
Failed to prepare pureed food as directed in recipe for 6 residents.
Failed to prepare, distribute, and serve food under sanitary conditions in kitchen.
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: 13.4
Weight loss percentage: 7.82
Weight loss: 6.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified failure to notify physician about weight loss and missing fentanyl patch |
| Registered Dietician CC | Registered Dietician | Reviewed residents with weight loss weekly and provided nutritional interventions |
| Dietary Staff FF | Dietary Staff | Prepared pureed pork fritters without cheese as per recipe, hair protruding from hairnet |
| Dietary Staff DD | Dietary Staff | Verified pureed food preparation concerns and environmental cleanliness |
| Nurse Aide L | Nurse Aide | Hair protruding from hairnet during meal service |
| Nurse Aide O | Nurse Aide | Verified unlocked storage room with hazardous chemicals |
| Administrative Nurse E | Administrative Nurse | Verified cognitively impaired residents and weight loss concerns |
| Nurse J | Nurse | Reported resident swallowing problems and poor appetite |
| Nurse Aide N | Nurse Aide | Reported resident appetite decline and refusal to eat |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 25, 2017
Visit Reason
This revisit inspection was conducted 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) were corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 26-41-201 (a)(b)
Deficiency related to regulation 26-41-104 (d)
Inspection Report
Re-Inspection
Census: 8
Deficiencies: 5
Date: Sep 26, 2017
Visit Reason
Licensure re-survey conducted at the attached assisted living facility in Junction City, KS on 9/25/17 and 9/26/17 to assess compliance with state regulations.
Findings
The facility failed to ensure the functional capacity screening form included all required elements and definitions for all residents. Negotiated Service Agreements lacked collaboration and necessary details for outside services. Health care services were not fully coordinated according to screenings and agreements. Disaster and emergency preparedness was deficient due to lack of quarterly review of the emergency management plan with employees and residents.
Deficiencies (5)
Facility's functional capacity screening form failed to 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 did not identify services, providers, or payment responsibilities for outside services.
Negotiated Service Agreement for resident #925 was not reviewed or revised at least once every 365 days.
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
Residents sampled: 3
Dates of inspection: 2017-09-25 to 2017-09-26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse #B | Interviewed regarding use of functional capacity screening form and health care service plans | |
| Administrative Staff #A | Interviewed regarding emergency management plan review | |
| Maintenance Supervisor #C | Interviewed regarding fire drill records and emergency drills | |
| Operator #D | Interviewed regarding resident disaster reviews and emergency preparedness |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Aug 23, 2016
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
The revisit confirmed that all previously cited deficiencies, identified by regulation numbers 483.10(b)(5)-(10), 483.10(b)(1), 483.20(d), 483.20(k)(1), 483.25(h), and 483.35(i), were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulations 483.10(b)(5)-(10), 483.10(b)(1)
Deficiency related to regulations 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.35(i)
Inspection Report
Plan of Correction
Deficiencies: 4
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 conducted on 08/17/2016.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, addressing deficiencies related to documentation, care plans, accident hazards, and sanitary food preparation.
Deficiencies (4)
Failure to maintain necessary documentation and notify residents of Medicare benefit discontinuation.
Failure to develop and maintain comprehensive care plans reflecting use of bed cane/positioning devices.
Failure to ensure resident environment is free of accident hazards, including side rail gap measurements.
Failure to ensure all food is prepared and distributed in a sanitary manner, including hair containment by dietary staff.
Inspection Report
Re-Inspection
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 the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies 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, resulting in a finding of substantial compliance effective August 23, 2016.
Deficiencies (1)
Most serious deficiencies found were an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated acceptance of plan of correction. |
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 visit included complaint investigations #93379 and #86746.
Findings
The facility failed to provide appropriate liability and appeal notices to residents, failed to develop comprehensive care plans including use of bed cane/positioning devices for some residents, failed to ensure the resident environment was free of accident/entrapment hazards related to bed rails/canes, and failed to prepare and serve food in a sanitary manner due to improperly secured hairnets on dietary staff.
Deficiencies (4)
Failed to provide appropriate liability and appeal notices for 3 of 6 residents reviewed.
Failed to develop comprehensive care plans that included use of bed cane/positioning devices for 2 of 3 residents reviewed.
Failed to ensure resident environment was free of accident/entrapment hazards related to bed rails/canes for 3 residents.
Failed to prepare and serve food in a sanitary manner due to dietary staff not properly securing hairnets.
Report Facts
Residents sampled for liability notices: 6
Residents with deficient liability notices: 3
Residents sampled for care plan review: 15
Residents with deficient care plans: 2
Residents with bed rail/cane entrapment hazards: 3
Facility census: 75
Side rail gap measurement: 7
Bed cane dimensions: 11
Bed cane dimensions: 6.25
Survey days with hairnet violations: 2
Inspection Report
Follow-Up
Deficiencies: 4
Date: May 12, 2016
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 have been corrected.
Findings
All deficiencies previously cited, identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.15(h)(2), 483.20(d)(3), 483.10(k), and 483.25(h), were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d)(3), 483.10(k)
Deficiency related to regulation 483.25(h)
Inspection Report
Plan of Correction
Deficiencies: 5
Date: May 4, 2016
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life in response to deficiencies cited during a complaint survey conducted on May 4, 2016.
Complaint Details
This Plan of Correction is related to a complaint investigation conducted on May 4, 2016, at Valley View Senior Life.
Findings
The facility identified multiple deficiencies related to resident mistreatment, neglect, abuse, environmental maintenance, care plan revisions, and accident prevention. Corrective actions and monitoring plans were implemented to address these issues.
Deficiencies (5)
Facility-wide system to assure correction and continued compliance with regulations.
Policies and procedures prohibiting mistreatment, neglect, abuse, and misappropriation of resident property.
Housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior, including repair of ductwork and wall damage.
Revision of care plans for residents based on condition changes and fall assessments.
Ensuring residents' environment is free of accident hazards and providing adequate supervision to prevent accidents.
Report Facts
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkens | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Added the Plan of Correction | |
| Irina Strakhova | Modified the Plan of Correction |
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, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
Deficiencies cited at 'E' level that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to survey findings and plan of correction acceptance. |
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 findings represent the results of 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 on 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 cognitive impairment and history of falls.
Deficiencies (4)
Failed to report to the state agency an extensive bruise of unknown origin for a cognitively impaired dependent resident.
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Failed to revise care plan for effective interventions to prevent future falls for a resident.
Failed to provide adequate supervision and effective interventions to prevent future falls for a resident.
Report Facts
Resident census: 83
Bruise size: 7
Bruise size: 10
Bruise size: 1.5
Fall frequency: 2
Fall injury size: 1.6
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 14, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at 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)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm that is not 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and is the Licensure Certification & Enforcement Manager at Kansas Department for Aging and Disability Services. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 2, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report shows that multiple deficiencies identified in prior inspections were corrected by April 20, 2015, as indicated by the correction completion dates next to each regulation cited.
Report Facts
Correction completion dates: 3
Inspection Report
Follow-Up
Deficiencies: 0
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 had been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of 04/20/2015, indicating compliance with the required standards.
Report Facts
Deficiencies corrected: 16
Inspection Report
Plan of Correction
Deficiencies: 17
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.
Findings
The facility has developed and implemented corrective actions to address multiple deficiencies including call light system testing, hydrotherapy unit safety, abuse prevention policies, assessment accuracy, care planning, infection control, staffing sufficiency, food safety, pharmaceutical services, and medication administration. Monitoring and staff education plans are in place to ensure ongoing compliance.
Deficiencies (17)
Failure to ensure weekly testing of call light system
Hydrotherapy units lacked ground-fault circuit interrupter
Policies and procedures to prohibit mistreatment, neglect, abuse, and misappropriation of resident property
Facility policy revised to address Elder Justice Act requirements
Inaccurate assessments of residents
Incomplete or inaccurate comprehensive care plans
Failure to revise care plans as indicated by changes in condition
Failure to provide necessary care and services to maintain well-being
Failure to prevent pressure sores or provide necessary treatment
Inadequate treatment for urinary incontinence
Failure to maintain a safe environment and prevent accidents
Improper use of antipsychotic drugs without diagnosis
Insufficient nursing staff to maintain resident well-being
Failure to record food temperatures and maintain sanitary food storage
Failure to provide pharmaceutical services to meet resident needs
Failure to develop infection control tracking system
Failure to ensure call light monitors are turned on at all times
Inspection Report
Enforcement
Deficiencies: 1
Date: Apr 2, 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 deficiency in the facility to be 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.
Deficiencies (1)
Most serious deficiency found to be a 'G' level
Report Facts
Denial of payment effective date: Jul 2, 2015
Noncompliance correction deadline: Oct 2, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkins | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning 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 based on multiple complaint numbers (#84028, 84058, 83812, 83721, 82725, 78511, 77225).
Complaint Details
The visit was complaint-related as it included a Health Resurvey and Complaint Investigation with multiple complaint numbers cited.
Findings
The facility failed to ensure the wireless call system monitors were turned on and functional, did not test the call system weekly as required, and failed to ensure the hydrocollator was plugged into a ground-fault circuit interrupter (GFCI).
Deficiencies (3)
The facility failed to ensure the monitors for the wireless call system were turned on, and the licensed nurse's pager was not functioning, resulting in staff not being notified when residents activated call lights.
The facility failed to test the wireless call system at least weekly to verify operation, testing only once a month.
The facility failed to ensure the hydrocollator was plugged into a ground-fault circuit interrupter (GFCI).
Report Facts
Census: 81
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Observed near call system monitor which was off; pager was not functioning |
| Maintenance Staff X | Maintenance Staff | Confirmed hydrocollator was not plugged into a GFCI |
| Administrative Staff A | Administrative Staff | Stated the facility did not turn the call system monitors on during the daytime |
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 if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payments effective date: Mar 3, 2015
Provider agreement termination date: Jun 3, 2015
Plan of correction submission timeframe: 10
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 enforcement letter. |
| Joe Ewert | Commissioner | Mentioned as Commissioner of KDADS in the report. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 31, 2013
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates when corrective actions were completed.
Findings
The revisit report confirms that the previously cited deficiency identified by regulation 26-42-102 (d) with ID prefix S5258 was corrected as of 12/31/2013.
Deficiencies (1)
Deficiency previously reported under regulation 26-42-102 (d) with ID prefix S5258
Report Facts
Deficiency correction date: Dec 31, 2013
Inspection Report
Follow-Up
Deficiencies: 5
Date: Dec 31, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that all previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of 12/31/2013.
Deficiencies (5)
Deficiency related to regulation 483.13(c)
Deficiency related to regulation 483.20(g)-(j)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Report Facts
Deficiencies corrected: 5
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 5
Date: Dec 17, 2013
Visit Reason
The inspection was conducted as 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 complete criminal background checks, inaccurate resident assessments, nutritional monitoring failures, medication regimen issues, and food sanitation violations.
Findings
The facility was found deficient in multiple areas including failure to obtain timely 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)
Failed to obtain results for criminal record checks in a timely manner for 1 of 5 staff members hired since the last survey.
Failed to accurately assess 1 of 19 sampled residents using the review instrument specified by the state and CMS.
Failed to maintain acceptable parameters of nutritional status and document percentage consumed of physician ordered supplements for 1 of 6 sampled residents.
Failed to ensure the resident's drug regimen was free from unnecessary medications when staff failed to follow physician ordered blood sugar parameters for 1 of 5 residents reviewed for medications.
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
Census: 86
Sample size: 19
Staff background check delay: 36
Deficiencies cited: 5
Blood sugar readings: 322
Blood sugar readings: 312
Blood sugar readings: 363
Inspection Report
Renewal
Census: 7
Deficiencies: 1
Date: Dec 17, 2013
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with staff qualifications and employee record requirements.
Findings
The facility failed to conduct timely criminal background checks for newly hired staff, specifically one Certified Medication Aide hired in November 2012 whose background check was completed only in January 2013, after the hire date. This failure indicates a lack of procedures to prevent mistreatment, neglect, abuse, or misappropriation of resident property.
Deficiencies (1)
Failure to conduct criminal record checks to assure prevention of mistreatment, neglect, abuse, or misappropriation of resident property for 1 of 1 staff member hired since October 2012.
Report Facts
Census: 7
Staff member with deficient background check: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse F | Administrative Nurse | Verified facility policy on criminal background checks for new hires |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Sep 20, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.20(d)(3), 483.10(k)(2), 483.25, and 483.25(h) were corrected as of 09/20/2013.
Deficiencies (4)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 4
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 regarding allegations of abuse, neglect, and failure to investigate and report incidents properly.
Complaint Details
The inspection was triggered by complaint investigations #67159 and #66631 concerning abuse, neglect, and failure to report and investigate incidents properly.
Findings
The facility failed to thoroughly investigate and report an injury from a coffee spill incident involving Resident #2, failed to review and revise the care plan accordingly, and failed to provide adequate care and supervision for Residents #1 and #2. Deficiencies included inadequate respiratory reassessment, failure to document and intervene for hypoglycemia, and insufficient supervision leading to accidents.
Deficiencies (4)
Failure to thoroughly investigate and report an accident resulting in injury for Resident #2 involving a coffee spill burn.
Failure to review and revise the plan of care for Resident #2 after the coffee spill incident.
Failure to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for Residents #1 and #2.
Failure to ensure the resident environment remained free of accident hazards and to provide adequate supervision to prevent accidents for Resident #2.
Report Facts
Resident census: 80
Coffee temperature: 164.5
Blood sugar reading: 36
Burn wound size: 1.5
Burn wound size: 13
Burn wound redness size: 15
Burn wound redness size: 11
Medication doses: 2
Medication doses: 2
Attempts to draw blood: 12
Oxygen saturation: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Provided statements regarding the coffee spill incident, burn evaluation, and resident supervision. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Nov 5, 2012
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
The report confirms that all previously cited deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 4
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 in response to deficiencies cited during a prior survey.
Findings
The facility identified multiple deficiencies related to resident dignity, housekeeping and maintenance, accident hazard prevention, and infection control. The Plan of Correction outlines specific corrective actions and education efforts to address these issues, with compliance targeted by November 5, 2012.
Deficiencies (4)
Failure to maintain resident dignity and respect during care and dining.
Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Failure to ensure the resident environment remains free of accident hazards.
Failure to establish and maintain an Infection Control Program to prevent disease and infection.
Report Facts
Number of corrective items completed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkens | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction. |
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 visit included complaint investigations #60127 and #60229. The facility was found noncompliant in areas related to dignity and respect, housekeeping, accident hazards, and infection control.
Findings
The facility failed to provide dignity and respect to residents, maintain housekeeping and maintenance services necessary for a sanitary and orderly environment, ensure an environment free of accident hazards, and maintain infection control practices especially related to oxygen therapy equipment.
Deficiencies (4)
Failed to provide dignity and respect to residents, including lack of privacy during toileting and inappropriate staff behavior during dining.
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on 3 of 4 halls.
Failed to provide an environment free of accident hazards for a resident with a history of falls by leaving the resident unattended on the toilet.
Failed to maintain infection control to prevent spread of infection, including improper storage of oxygen therapy equipment.
Report Facts
Census: 87
Sample size: 29
Non-injury falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Nurse | Verified staff should provide privacy during toileting and stay with resident in bathroom; verified staff did not provide dignity and respect. |
| Nurse Assistant H | Nurse Assistant | Observed making inappropriate faces at a resident and made disrespectful comments. |
| Dietary Staff I | Dietary Staff | Verified staff should not make faces at residents or refer to feeding residents as 'feeding'. |
| Nurse A | Nurse | Observed leaving resident alone on toilet without assistance. |
| Nurse Assistant B | Nurse Assistant | Verified resident should not be left alone on toilet and staff should watch for unsafe toileting attempts. |
| Nurse I | Nurse | Verified C-PAP tubing and mask were contaminated if lying on floor or bedside table and should be stored properly. |
| Maintenance Staff E | Maintenance Staff | Verified housekeeping and maintenance deficiencies during environmental tour. |
| Maintenance Staff F | Maintenance Staff | Verified housekeeping and maintenance deficiencies during environmental tour. |
| Administrative Staff G | Administrative Staff | Verified housekeeping and 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 addressing 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 handling.
Deficiencies (6)
Facility-wide system to assure correction and compliance with regulations.
Policies and procedures prohibiting mistreatment, neglect, abuse, and misappropriation of residents' property; criminal background checks for employees.
Use of state-approved review instrument for accurate resident assessments.
Ensuring acceptable nutritional status parameters and recording physician-ordered supplements.
Ensuring resident medication regimens are free from unnecessary medications and nursing education on blood sugar notification.
Storing, preparing, and serving food under sanitary conditions, including glove usage and discarding contaminated items.
Report Facts
Plan of Correction completion date: Dec 31, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkens | Administrator | Submitted the Plan of Correction |
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 in response to deficiencies cited during a prior survey.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, addressing deficiencies related to mistreatment, neglect, abuse, and misappropriation of residents' property. Policies include criminal background checks for employees prior to employment.
Deficiencies (2)
Facility-wide system to assure correction and compliance with regulations.
Development and implementation of policies prohibiting mistreatment, neglect, abuse, and misappropriation of residents' property, including criminal background checks for employees.
Report Facts
Plan of Correction completion date: Dec 31, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkens | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: N031003 POC E2NJ11
Visit Reason
This document is a Plan of Correction submitted by Valley View Senior Life in response to deficiencies cited during a complaint survey.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey.
Findings
The plan outlines corrective actions to address deficiencies related to mistreatment, neglect, abuse reporting, care plan accuracy, resident care and safety, and environmental hazards such as safety with a public coffee pot.
Deficiencies (5)
Facility-wide system developed to assure correction and continued compliance with regulations.
Ensure all alleged violations involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property are reported immediately.
Use assessment results to develop, review, and revise residents' comprehensive Plan of Care accurately reflecting individual needs and safety.
Ensure each resident receives necessary care and services to attain or maintain highest practicable physical, mental, and psychosocial well-being.
Ensure resident environment remains free of accidents and hazards; provide adequate supervision and assistive devices to prevent accidents.
Report Facts
Complete Date: Sep 20, 2013
Event ID: E2NJ11 (alphanumeric identifier)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyrone Wilkens | Administrator | Submitted the Plan of Correction |
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