GARDEN VALLEY RETIREMENT VILLAGE KS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
04/19/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
04/19/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
04/19/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
04/19/2010	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
04/19/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/19/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
04/19/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
04/19/2010	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
04/19/2010	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
04/19/2010	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
04/19/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
04/19/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/19/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/11/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/11/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
01/11/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
01/11/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
01/11/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
01/11/2010	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
02/03/2009	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Widespread	Potential for minimal harm
02/03/2009	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
02/03/2009	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Immediate jeopardy to resident health or safety
02/03/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Isolated	Minimal harm or potential for actual harm
02/03/2009	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
02/03/2009	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
02/03/2009	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Actual harm
02/03/2009	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Actual harm
02/03/2009	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
02/03/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Give each resident enough fluids to keep them healthy and prevent dehydration.	Pattern	Minimal harm or potential for actual harm
02/03/2009	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
02/03/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
02/03/2009	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
02/03/2009	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
02/03/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/03/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
02/03/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
02/03/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
12/09/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
12/09/2008	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
12/09/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
12/09/2008	restrictions on the use of flammable curtains.	Widespread	Minimal harm or potential for actual harm
01/23/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
01/23/2008	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Provide clean bed and bath linens that are in good condition.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
01/23/2008	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
01/23/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
01/23/2008	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
01/23/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Actual harm
01/23/2008	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
01/23/2008	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
01/23/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
01/23/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
01/23/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Actual harm
01/23/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
01/23/2008	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
01/23/2008	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Minimal harm or potential for actual harm
01/23/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
01/23/2008	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
01/23/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
01/23/2008	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
01/23/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/23/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
01/23/2008	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
01/23/2008	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
01/23/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
01/23/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death