Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
honored residents’ dignity and respect when they failed to provide haircuts according to
resident needs and choices for two out of 26 sampled residents (Residents #95 and #30),
and when staff failed to ensure residents were appropriately covered when in public, which
affected one resident (Resident #66). The facility census was 102.
Review of the un-dated booklet entitled, Resident Rights For Long-Term Care In Missouri,
provided through Missouri’s Long-Term Care Ombudsman (an advocate) Program, showed
residents should e treated with consideration and respect, with full recognition of their
dignity and individuality.
Review of the facility’s policy for routine resident care, last reviewed 4/6/16, showed:
-Routine resident care is care that is not necessarily medically or clinically based, but
necessary for quality of life, promoting dignity and independence, as appropriate.
-It is the policy of this facility to promote resident centered care by attending to the
physical, emotional, social and spiritual needs and honor resident lifestyle preferences
while in the care of this facility.
-Licensed staff are to assess, implement (including appropriate delegation) and evaluate
for personal needs including emotion, social and spiritual needs.
1. During the resident group interview on 1/24/19 at 1:31 P.M. residents said the facility
did not have someone who provides haircuts. There were a couple volunteers around
Christmas but there is not someone who regularly provides haircuts.
2. Review of Resident #95’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/11/19, showed:
-Received Medicaid;
-Cognitively intact.
During an interview on 1/22/19 at 10:53 A.M., the resident said he/she:
-Had not had his/her hair cut in four months;
-Was on Medicaid and had not been offered a hair cut.
-Was working with the administrator to get a licensed hair salon in the facility.
During an interview and observation on 1/28/19 at 9:49 A.M., observation showed, and the
resident said:
-The resident wanted a haircut
-The resident’s hair was over his/her ears;
-Per the administrator, the facility had not had anyone to give hair cuts in awhile.
3. Review of Resident #30’s annual MDS, dated [DATE], showed:
-Sometimes makes self understood;
-[DIAGNOSES REDACTED].>-Received Medicaid.
During an observation and interview on 1/24/19 at 12:04 P.M., the resident indicated to
Certified Nurse Aide (CNA) E that he/she wanted a haircut. CNA E said someone would be
coming to the facility soon to cut his/her hair and CNA E would put him/her on the list.
CNA E said the facility recently replace the beautician. The resident’s hair was, at
least, to his/her ears and hung down the back of his/her neck.
During an interview on 1/25/19, the social services designee (SSD) said:
-Facility staff have done some research related to obtaining a licensed beautician.
-Resident #95 had talked with the administrator about arranging for one.
-The SSD had talked with someone who might be willing to provide haircuts for residents
who received Medicaid.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-He/she did not know of anyone who currently provided free haircuts for residents who
received Medicaid and did not know how long this service had not been available.
4. Review of Resident #66’s care plan, revised, 8/26/18, showed:
– Activities of daily living (ADL) self care performance deficit related to left [MEDICAL
CONDITION];
– Required extensive staff assistance participation to dress.
Review of the resident’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 11/19/18, showed:
– Cognitive skills intact;
– Required extensive assistance of one staff for dressing and personal hygiene;
– [DIAGNOSES REDACTED].
Observation on 1/24/19, at 4:46 P.M., showed:
– The resident propelled him/herself down the 200 hall and passed various staff;
– The resident had approximately four inches of the left side of his/her abdomen and
across to the right side of his/her abdomen visible where his/her shirt and pants did not
meet;
– The resident stopped at the center court nurse’s station and spoke with Licensed
Practical Nurse (LPN) C and then went outside to smoke;
– LPN C did not attempt to readjust the resident’s clothing.
During an interview on 1/25/19, at 10:13 A.M., LPN C said:
– The resident’s skin should not be showing in public areas;
– The resident’s skin should have been covered, his/her clothes adjusted.
Observation on 1/25/19, at 4:23 P.M., showed:
– The resident was in the television room by the center court nurse’s station;
– Approximately three inches of the resident’s abdomen was visible where his/her shirt and
pants did not meet.
During an interview on 1/28/19, at 11:43 A.M., the Director of Nursing (DON), said:
– Residents’ skin should not be showing in public or common areas;
– Staff should assist with adjusting the resident’s clothing.

F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to create an environment
respectful of the right of each resident when staff did not offer an evening snack to each
resident. This affected three out of 26 sampled residents (Residents #22, #20 and #95) and
others who attended the group resident interview. The facility census was 102.
1. Review of Resident #22’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/8/19, showed:
-Cognitively intact;
-Required extensive assistance for transfers;
-Used a wheelchair for mobility;
-Very important to have snacks available between meals.
During an interview on 1/22/19 at 10:33 A.M., the resident said:
-Staff did not offer evening snacks to residents.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-Residents have to go to the nurses’ station and get snacks themselves.
-The snacks were too high to reach if residents were in a wheelchair.
2. Review of Resident #70’s annual MDS, dated [DATE], showed:
-Cognitively intact;
-Required total assistance for transfers;
-Used a wheelchair for mobility;
-Impairment of range of motion of both upper extremities;
-Somewhat important to have snacks available between meals.
During an interview on 1/22/19 at 3:01 P.M., the resident said:
-Staff do not offer snacks to residents, evening or otherwise.
-He/she would at least like to have a banana.
3. Review of Resident #95’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Independent for most care;
-Used a wheelchair for mobility.
During an interview on 1/22/19 at 11:13 A.M., the resident said:
-Staff do not offer snacks room to room of an evening.
-They put the snacks at the nurses’ station and they may last 15-20 minutes, then they are
all gone.
4. Review of Resident #42’s quarterly MDS, dated , 10/30/18, showed:
– Cognitive skills intact;
– Supervision with meal set up;
– [DIAGNOSES REDACTED].
During an interview on 1/22/19, at 10:56 A.M., the resident said:
– Staff do not come to our room and offer a snack at bedtime;
– Staff leave a tray at the nurse’s station and there’s not enough snacks on there for the
entire hallway;
– Certain residents take a lot of them and then trade them for cigarettes.
5. Review of Resident #9’s annual MDS, dated , 12/25/19, showed:
– Cognitive skills intact;
– Supervision with meal set up;
– [DIAGNOSES REDACTED].
During an interview on 1/22/19, at 11:17 A.M., the resident said:
– Staff do not come to our room and offer us a snack at bedtime;
– A tray of snacks is left at the nurse’s station but there’s not enough for the entire
hall.
6. During the resident group interview on 1/24/19 at 1:31 P.M. residents said snacks were
not offered personally by staff. Two or three people grab what is on the tray that is left
out in the hall and some residents do not get any. All residents agreed they would like to
have a snack offered at bedtime.
7. During an interview on 1/28/19 at 11:45 A.M., the Director of Nurses (DON) and
Assistant DON (ADON) said:
-Residents who were able to come get their snacks do come and get them.
-Staff should offer all residents a snack at bed time.
-Nurses should monitor to ensure that snacks are passed and that the amount consumed is
documented.
– There’s a tray of snacks left at the nurse’s station;
– If a resident wanted a snack, they could go and get one and if they were not able to,
the staff should offer a snack to every resident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0577

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Allow residents to easily view the nursing home’s survey results and communicate with
advocate agencies.

Based on observation and interview the facility failed to notify residents of the current
availability and location of the most recent survey results and facility plan of
correction. The facility census was 102.
1. During a resident group interview on 1/24/19 at 1:31 P.M. one resident said the survey
book should have been by the licenses but he/she has not been able to find it lately.
Observations throughout the survey on 1/22/19, 1/23/19, 1/24/19, 1/25/19, and 1/28/19
showed:
– The survey book was not able to be located in the facility;
– The facility did not post a sign indicating the location of the survey result book.
Review of Resident #95’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/11/19, showed:
– Able to make daily decisions without difficulty;
– No mood or behavior problems.
Observation and interview on 1/28/19 at 8:45 A.M., showed the resident maneuvered his/her
electric wheelchair down the hallway to in front of the surveyor. The resident asked if
the facility was responsible to post for the residents to see a copy of the results of the
inspectors survey. The resident said there was a small book in the front of the facility
for a while but a few weeks ago the notebook was moved and never returned. The new people
in the office did not know the whereabouts of the notebook.
During an interview on 1/28/19 at 3:05 P.M., the Director of Nursing (DON) said:
– She and the Administrator began employment at the facility at the same time and toured
the facility at the same time;
– While on tour, she asked about the survey results notebook and nobody knew where it was.
During an interview on 1/28/19 at 3:15 P.M., the Nursing Staff Scheduler (NSS) told the
Administrator he/she thought the Survey Result Book was sitting on a shelf, locked up back
in the old DON office. The Administrator said he would find the book.
Review on 1/28/19 at 3:55 P.M., showed the Administrator with a thin white notebook with
the previous year survey results inside. The facility’s plan of correction was not
included in the Survey Results Book.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, the facility failed to clarify code status upon
admission and failed to document the resident’s code status on the resident’s admission
record in such a way to be readily accessible to staff in the event of an emergency for
one of 26 sampled residents, (Resident #42). The facility census was 102.
1. Review of the facility’s general code status policy, dated, [DATE], showed, in part:
– This policy is applicable to all adult living centers;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
– It is the intent of this facility to honor the wishes and rights of the
resident/representative to make the determination of what, if any, resuscitative measures
will be implemented in the event the resident’s respirations and/or pulse cease either by
natural or unnatural causes;
– The purpose of this policy is to guide clinical staff to quickly and accurately identify
residents in the facility that do and do not request CPR (cardiopulmonary resuscitation,
an emergency response treatment that includes calling 911, initiating compression of the
chest, initiating suction as appropriate, and supplying artificial oxygenation, and use of
automated external defibrillator (AED) if available and appropriate, for the purpose of
circulating oxygen to the vital organs until a higher level of care can be accessed), as a
treatment for [REDACTED].
– An efficient and accurate method of determining the code status of a resident during a
medical emergency is needed;
– The use of an electronic health record (EHR) provides for fast retrieval to identify and
how to appropriately respond to respiratory and [MEDICAL CONDITION] based upon the
resident/representative wishes;
– Code status is found in the EHR and will be used by the nurse to validated code status
before initiating CPR;
– Upon admission to the facility, a code status will be entered into the resident’s
profile for immediate access.
2. Review of Resident #42’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, [DATE], showed:
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised, [DATE], showed:
– Staff did not care plan the resident’s code status.
Review of the resident’s electronic medical record showed staff had not indicated the
resident’s preference for code status.
Review of the resident’s admission record, showed:
– admitted [DATE];
– The code status was not documented.
Review of the resident’s physician order [REDACTED].
– Staff did not add the resident’s desired code status to alert staff if the resident
wished for CPR to be performed in the event his/her heart stopped beating or he/she went
into respiratory distress.
During an interview on [DATE], at 2:36 P.M., the social services designee (SSD) said:
– Social services did the social history and would ask the resident if they wanted a
living will;
– Would look at the face sheet to determine the resident’s code status;
– Corporate office entered the information on the resident’s admission records;
– He/she looked at the resident’s electronic medical chart and did not find a code status;
– The resident should have a code status and it should be listed on the admission record.
During an interview on [DATE], at 11:43 A.M., the Director of Nursing (DON) said:
– All residents should have a code status on their profile or admission record.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain a clean, homelike
environment. The facility census was 102.

1. Observation on 1/22/19, at 10:15 A.M., of room [ROOM NUMBER] showed:
– The right hand side of the closet door had a hole in it;
– The plywood on the back of the bathroom door was busted with jagged edges;
– The wall in the bathroom had three separate holes in it, approximately baseball size;
– Above the baseboard in the bathroom by the toilet, an area had been patched and had a
slit in it;
– The tile around the toilet had grime and dirt around it;
– Several areas of the wall had been patched, was not covered with paint.
2. Observation on 1/22/19 at starting at 12:14 PM in the 500 hall’s (locked unit) common
area showed the following:
– A softball sized half-moon black substance on ceiling.
– A tan recliner used by residents with multiple brown stains in seat, arm rest and back;
– A pink recliner with brown grim on both arm rests;
– Three dining room chair with foam exposed on the seat;
– The window to courtyard with splatters, smears;
– The white door to courtyard with black scuff marks across bottom 12 inches;
– In room [ROOM NUMBER] showed a softball sized dent in the closet door.
– In room [ROOM NUMBER], the hot water was not working at the sink, it only had a slow
drip when the hot water handle was turned to the on position.
During an interview on 01/25/19 at 9:35 AM Housekeeping staff A said he/she had worked
here two months and anytime they see any repairs, they put in a work order kept at the
nurses station or will find the maintenance staff.
In an interview at 4:00 P.M., the maintenance supervisor said staff don’t always fill out
the work orders.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on record review and interview the facility staff failed to conduct all required
background checks. Staff did not check the Certified Nurses’ Assistant (CNA) Registry for
all staff to ensure they did not have a Federal Indicator (a marker given by the federal
government to individuals who have committed abuse/neglect). The facility census was 102.
1. Review of the facility policy dated 10/1/00 titled Background checks/EDL Checks Under
Missouri Law did not address checking the CNA Registry.
2. Review of the Director of Nursing (DON) employee file showed:
– Date of hire 1/7/19;
– No CNA Registry check found.
3. Review of Licensed Practical Nurse (LPN) H’s employee file showed:
– Date of hire 10/18/18;
– No CNA Registry check found.
4. Review of LPN I’s employee file showed:
– Date of hire 3/14/18;
– No CNA Registry check found.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
5. Review of LPN D’s employee file showed?
– Date of hire 8/15/18;
– No CNA Registry check found.
6. Review of the Administrator’s employee file showed:
– Date of hire 1/2/19;
– No CNA Registry check found.
7. Review of the Assistant DON’s employee file showed:
– Date of hire 7/10/18;
– No CNA Registry check found.
8. During an interview on 01/28/19 at 3:33 P.M. The Human Resources Manager said she
completes criminal background checks and she did not know CNA Registry had to be checked
for non-CNA employees.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident completely in a timely manner when first admitted, and then
periodically, at least every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure resident
Minimum Data Set (MDS) were completed accurately for three of 21 sampled residents,
(Resident’s #25, #103 and #42). The facility census was 102.
1. Review of Resident #25’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 10/17/18, showed:
– Long and short term memory problems;
– No impairment to the upper and lower extremities;
– [DIAGNOSES REDACTED].
Observation and interview on 1/22/19, at 2:36 P.M., showed:
– The resident lay in bed;
– Family member A was at bedside;
– Family member A said the resident had a stroke and was paralyzed (partly or wholly
incapable if movement) on the right side.
2. Review of Resident #42’s physician order [REDACTED].
– Start date: 9/26/18: an order for [REDACTED].
Review of the resident’s quarterly MDS, dated , 10/30/18, showed:
– Cognitive skills intact;
– In the last five days, the resident did not receive scheduled pain medications, did not
receive any as needed pain medications and did not use any non medication interventions;
– Pain level was not assessed;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
– Start date: 9/26/18: an order for [REDACTED].
Review of the resident’s Medication Administration Record [REDACTED]
– The resident received [MEDICATION NAME] 20 times for pain.
3. During an interview on 1/28/19, 11:43 A.M., the Director of Nursing (DON) said:
– If a resident is receiving pain medication, the MDS section for pain should be filled
out;
– If the resident had an impairment on one side of their body or both sides, the MDS
should identify it.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
4. Review of Resident #103’s medical record showed:
– Date of admission 4/24/18;
– The resident’s most recent MDS, dated [DATE] showed the resident showed evidence of an
acute change in mental status;
– Review of the resident’s Brief Interview for Mental Status (BIMS) was not completed.
During an interview on 1/25/19 at 10:49 A.M.- The MDS Coordinator said-
– The BIMS was not completed because the Social Services Assistant being trained, it
should have been completed.
– She was told she could not do BIMS after assessment review date. The social services
assistant should have completed the paper assessment but cannot answer why he/she did not.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a care plan consistent with the resident’s specific conditions, needs and risks
to provide effective person centered care for one of 26 sampled residents, (Resident #102
). The facility census was 102.
1. Review of Resident # 102’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/11/18, showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for transfers;
– Had one stage 3 pressure ulcer (a full thickness of skin is lost, exposing the
subcutaneous tissues) which was present of admission;
– [DIAGNOSES REDACTED].
Review of the resident’s undated care plan, showed:
– The resident had a pressure ulcer on the left buttock;
– The resident had an activities of daily living (ADL) self care performance deficit
related to [MEDICAL CONDITION];
– The resident required physical assistance of two staff with transfers.
– The care plan did not indicate what type of device to use to assist the resident with
transfers.
Observation and interview on 1/24/19, at 10:01 A.M., showed:
– Licensed Practical Nurse (LPN) C provided wound care to the resident and said the wound
was located on the resident’s sacrum (area at the base of the spinal column).
Observation on 1/25/19, at 11:20 A.M., showed:
– Certified Nurse Aide (CNA) E and CNA B transferred the resident with the use of a gait
belt ( a special belt placed around the resident’s waist to provide a handle to hold onto
during a transfer).
During an interview on 1/28/19, at 11:43 A.M., the Director of Nursing (DON) said:
– The care plans should have the correct location of the wounds;
– The care plans should specify how to transfer the resident was to be transferred.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff
followed professional standards of care when staff failed to check placement of
gastrostomy tube (G tube, tube surgically inserted through the abdominal wall into the
stomach for administration of food, fluids and medications), for one of 26 sampled
resident’s, (Resident #72), did not watch (Resident #45) take medications when
administered which the resident then kept at bedside, did not follow the physician’s order
to obtain labs for (Resident #80) and failed to allow Resident #3 and Resident #37’s
fingertip to air dry before obtaining the blood sample. The facility census was 102.
1. Review of the facility’s medication administration by enteral tube (a way to provide
food or medications through a tube placed in the nose, stomach or the small intestine)
policy, revised, 11/23/18, showed, in part:
– This policy addresses guidance for the clinical administration of medications through a
G- tube;
– Check the placement of the tube before administering medication and/or fluids.
2. Review of Resident #72’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/5/18, showed:
– Cognitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order sheet (POS), dated, January, 2019, showed:
– an order for [REDACTED].>- Check for residual prior to each intermittent feeding; if
greater than or equal to 100 cc., hold tube feeding . Check residual again in two hours.
Notify physician and /or Nurse Practitioner when appropriate;
– The physician’s order did not specify to check for placement prior to administering
medications and/or tube feedings.
Review of the resident’s Medication Administration Record, [REDACTED]
– Enteral feed order every day and evening shift. Check for residual prior to each
intermittent feeding; if greater than or equal to 100 cc., hold tube feeding. Check
residual again in two hours. Notify physician and /or Nurse Practitioner when appropriate;
– Did not specify to check for placement prior to administering medications and/or tube
feedings
Observation on 1/25/19, at 7:45 A.M., showed:
– Licensed Practical Nurse (LPN) B opened the new irrigation tray with piston syringe and
placed the plastic drape over the resident’s lap;
– Attached the syringe with the plunger to the [DEVICE] and drew back approximately 30 ml
of residual and reinserted it;
– LPN B removed the syringe and removed the plunger and re-attached the syringe to the
[DEVICE];
– LPN B flushed with 30 ml. of water and then administered the resident’s medication;
– LPN B did not check for placement before checking for residual.
During an interview on 1/28/19, at 11:09 A.M., LPN B said:
– He/she should have used a stethoscope and checked for placement.
During an interview on 1/28/19, at 11:43 A.M., the Director of Nursing (DON) said:
– Staff should use a stethoscope and check for placement before administering medications.
3. Review of the facility’s blood glucose point of care testing policy, revised 5/23/18,
showed, in part:
– The importance of ongoing glucose monitoring is necessary to detect extremes of high or

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
low blood glucose levels to evaluate the effectiveness of the treatment plan;
– Prepare finger to be lanced by having resident wash hands thoroughly with soap and warm
water or use an alcohol wipe and allow to air dry before lancing.
Review of resident #3’s POS, dated, January, 2019, showed:
– an order for [REDACTED].
Observation on 1/24/19, at 11:14 A.M., showed:
– LPN A placed a paper towel on the resident’s table and placed the glucometer, alcohol
pad, lancet, and insulin pen on the paper towel and placed the strip in the glucometer;
– LPN A cleaned the resident’s finger with an alcohol wipe, did not let the fingertip air
dry and obtained the resident’s blood sample.
4. Review of Resident #37’s POS, dated, January, 2019, showed:
– an order for [REDACTED].
Observation on 1/24/19, at 11:32 A.M., showed:
– LPN A cleaned the resident’s finger with an alcohol wipe, did not let the fingertip air
dry and obtained the resident’s blood sample.
During a telephone interview on 1/31/19, at 1:12 P.M., LPN A said:
– He/she should have let the fingertip air dry before obtaining the blood sample.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
– Staff should let the fingertip air dry before obtaining the blood sample.
5. Review of Resident # 45’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Independent with most activities of daily living;
– [DIAGNOSES REDACTED].
Resident’s care plan, revised on 1/24/19, showed:
– Give medications as ordered. Monitor/document side effects and effectiveness.
Review of the resident’s January, (YEAR) physician’s order sheet, showed the physician
ordered:
– Artificial Tears 0.4 % Instill one drop as needed for dry eyes;
– [MEDICATION NAME] Solution 0.5-2.5 milligram/3 milliliters (mg/3 mg) one vial, inhale
four times daily for [MEDICAL CONDITION];
– [MEDICATION NAME] Suspension 0 units/ml Give five ml orally four times a day for thrush
for 14 days, swish and swallow;
ProAir HFA aerosol solution 108 mcg/act (micrograms/actuation) inhale two puffs orally as
needed (PRN) for shortness of air and wheezing.
Observation and interview on the following dates showed medications left in the resident’s
room.
– 1/24/19 at 5:10 P.M., a bottle containing Tums (antacid), a bottle of artificial tears
(eye drop for dry eyes), ProAir inhaler (treats shortness of air and wheezing), and a vial
of [MEDICATION NAME] (aerosol treatment for [REDACTED].
– The resident said staff could not always get to him when he/she had trouble breathing so
they left that down in the room with him/her so he/she could take it if he/she needed to
and staff had not got to him/her for a while.
– 1/25/19 at 9:35 A.M., showed the resident sat on the side of his/her bed. On a bedside
cabinet sat three plastic medication cups. Two medication cups held more tan 15
centimeters cc of [MEDICATION NAME] suspension and one medication cup that held more than
10 cc of [MEDICATION NAME] suspension.
– The resident said he/she used that medication to swish around in his/he mouth when
finished with eating. He/she did not always rinse and spit after his/her inhaler use and
sometimes got sores in his/her mouth. The medication seemed to coat his/her mouth and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
throat, so he/she did not always want to take it when staff brought it to him/her. Staff
left it so he/she could use it when needed. The nurses didn’t know he/she had kept that
much back, they just sit it down and do not watch me take it.
During an interview on 1/28/19 at 11:45 A.M., the Director of Nurses (DON) said:
-Staff should watch the residents take their medications;
– Only the resident’s that staff had assessed were capable of taking their own medications
should have any medications at bedside.
During an interview on 1/28/19 at 12:47 P.M., the Assistant DON looked through the
resident’s medical record and said:
– Staff had not assessed the resident to keep medication at bedside.
6. Review of Resident #80’s MDS, dated [DATE], showed:
– Both long and short term memory problems;
– Required assistance with all activities of daily living.
– [DIAGNOSES REDACTED].
Review of the resident’s January, 2019 physician order sheet showed on 1/7/19, the
physician ordered:
– [MEDICATION NAME] Sodium Solution Reconstituted (IV antibiotic) one gram (gm). Use one
gram intravenously (IV) every morning and at bedtime for a urinary tract infection.
– Laboratory ordered 1/7/19, draw a Complete Blood Count (CBC) and
a Comprehensive Metabolic Panel (CMP) every weekly on Fridays while on IV antibiotic until
2/8/19.
Review of the resident’s medical record on 1/23/19 at 11:24 A.M., showed no laboratory CBC
and CMP results.
During an interview on 1/25/19 at 2:45 P.M., the DON said she had looked at the resident’s
records and found staff had not had the the resident’s blood drawn while on IV
antibiotics. She put in an order to have the blood drawn STAT (immediately).

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to complete a discharge summary
for one of three sampled resident (Resident #108) when the resident was discharged from
the facility. The facility census was 102.
1. Review of the facility policy dated 3/10/17 titled Transfer and Discharge Policy
showed:
– When a resident’s discharge is anticipated, facility will develop and implement a
discharge plan that focuses on the resident’s goals, the preparation of residents to be
active partners and effectively transition them to post-discharge care, and the reduction
of factors leading to preventable readmissions.
– When a discharge is anticipated, the facility will develop a discharge summary that
includes, but is not limited to the following:
1. Summary of Stay;
2. Final Summary Available for Release;
3. Medication Reconciliation;
4. Post-Discharge Plan of Care;
– A copy of the post-discharge plan will be provided to the resident, and with the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
resident’s consent, the resident rpresentative(s), the receiving provide, if applicable,
and a copy will be filed in the resident’s medical record.
2. Review of Resident #108’s medical record showed:
– admitted [DATE];
– discharge date [DATE];
– There was no discharge summary or post discharge plan of care found in the records.
During an interview on 1/28/19 at 4:20 P.M. the Director of Nursing (DON)said she did not
know who the resident was.
During an interview on 1/28/19 at 4:28 P.M. the Social Services Designee said the resident
was discharged back to the assisted living facility he/she came from;
-He/she did not complete a discharge summary or post-discharge plan of care for the
resident.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide adequate
incontinent care for two residents (Residents #25, #30) out of 26 sampled residents who
required assistance, and failed to provide baths/showers and grooming for dependent
residents. This affected three sampled residents (Residents #9, #22, #43) and Resident’s
#15 and #91. The facility census was 102.
1. Review of the facility’s policy related to bathing and showering, revised 4/25/18,
showed:
-Determine resident preference for shower or bathing;
-Determine resident preference for morning or evening bathing;
-Determine resident preference for number of baths/showers per week;
-Care plan resident preferences and communicate to staff providing personal care;
-Residents have the right to refuse care, including bathing;
-Attempt and document attempts for alternative bathing options
-Provide oral care-brush teeth or clean dentures;
-Brush/comb hair as applicable;
-Men should be shaved during bathing, if applicable.
2. Review of Resident #22’s bathing documentation from 10/28/18 through 1/25/19, showed:
-Nine documented showers, including one refusal;
-Up to seven to twenty eight days between documented showers;
-Only one week that staff documented the resident received two showers in one week.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/8/19, showed:
-Cognitively intact;
-Required extensive assistance for transfers, dressing, toileting and bathing;
-Occasionally incontinent of bladder;
-Continent of bowel;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised on 1/17/19, showed:
-Had bowel and bladder incontinence;
-Bathing per choice. See bath schedule;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-Required physical assistance with bathing/showering (at least two times per week) and as
necessary or requested.
During an interview on 1/22/19 at 10:30 A.M., the resident said:
-He/she did not receive his/her showers as scheduled and just had to make do without a
shower.
-He/she washed his/her face at the sink but did not always get his/her scheduled shower,
but would like to.
3. Review of Resident #43’s bathing documentation from 11/6/18 through 1/25/19 showed:
-Eight documented baths/showers, including two refusals and four bed baths;
-Up to eight to 31 days between documented baths/showers;
-Only two weeks that staff documented the resident received two baths/showers per week.
Review of the resident’s care plan, last revised 1/13/19, showed:
-Had a urinary catheter (sterile tube inserted into the bladder to drain urine);
-Had a recent urinary tract infection;
-Required extensive assistance for personal hygiene;
-Bathing scheduled for every Tuesday and Friday, per resident’s choice;
-Often refused his/her shower;
-Return later and offer shower again if refused.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Total dependence on staff for transfers and bathing;
-Required extensive assistance for personal hygiene;
-Had a urinary catheter and a [MEDICAL CONDITION] (an opening from the colon, through the
abdominal wall);
-[DIAGNOSES REDACTED].
During observation and interview on 1/24/19 at 9:22 A.M., observation showed, and the
resident said:
-The resident lay in bed and an unpleasant odor was noted when staff removed the
resident’s covers.
-After staff completed care, the resident said he/she had not had a shower/bath in several
weeks, but staff said he/she would get one that day.
-He/she thought he/she should get a bath/shower two times a week, but was not sure on what
days.
-He/she would like to get his/her baths/showers as scheduled.
4. Review of Resident #9’s care plan, revised, 3/6/18, showed:
– Self care performance deficit related to [MEDICAL CONDITION] (MS, a progressive
deteriorating nervous system disease that results in a gradual loss of muscle function);
– Required extensive assistance to totally dependent with one staff to provide a bath at
least twice weekly.
Review of the resident’s annual MDS, dated [DATE], showed:
– Cognitive skills intact;
– Dependent on the assistance of two staff for transfers;
– Required extensive assistance of two staff for dressing;
– Bathing did not occur;
– [DIAGNOSES REDACTED].
Review of the resident’s bath records from 11/2/18 thru 1/21/19, showed:
– 11/2/18- Staff did not document the shower had been completed;
– The resident had a shower on 11/20/18, 12/4/18 and 12/21/18.
5 Review of Resident #15 ‘s MDS dated [DATE] showed staff assessed the resident with
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
severe cognitive impairment and required extensive assistance with personal hygiene.
Review of Resident #91 ‘s MDS dated [DATE] showed staff assessed the resident with
moderate cognitive impairment and extensive assistance with dressing and personal hygiene.

In an interview on 1/25/19 at 11:46 A.M. , CNA I said all residents are given showers two
times per week. Shower sheets are turned into the charge nurse.
Observation on 1/25/19 (Friday) at 4:00 P.M. showed Resident’s #15 and #91 in the common
area with uncombed, greasy looking hair.
Observation on 1/28/19 (Monday) at 9:24 A.M. showed Resident #15 and #91 sitting in the
common room with uncombed, greasy looking hair and unkempt clothing.
In an interview on 1/28/19 09:30 A.M. CNA J said when he/she gets residents up in the
morning, staff pick out their clothes, takes them to the toilet, washed their face and
combed their hair.
Review of shower sheets for Resident #15 showed in January, 2019, the resident received
showers on 1/1, 1/8, 1/21, and 1/24.
Review of shower sheets for Resident #91 showed in January, 2019, the resident received
showers on 1/8, 1/16, and 1/21.
6. During an interview on 1/28/19, at 11:43 A.M., the DON said:
– They have shower aides who are assigned to give showers;
– The nurses are responsible to make sure the showers are being done;
– Staff should fill out the shower sheets;
– If there was a blank area on the shower sheet, she would say the resident didn’t get
their showers;
– If a resident wanted a shower twice weekly, that is how it should be scheduled.
7. Review of the facility’s policy and procedure for Perineal Care, revised 9/6/17,
showed:
– To promote a sense of well-being and meets hygiene standards of care;
– Perform after incontinence of bowel, bladder, as needed and at least twice per shift for
residents wearing incontinence products;
– Includes cleansing of the perineum, from the pubis symphysus bone to the coccyx area;
– Begin with the front genital area first and end with the coccyx area;
– Cleanest to dirtiest;
– Manipulate and thoroughly cleanse all perineal skin areas and inner thighs.
8. Review of Resident #30’s care plan, last revised on 12/20/18, showed:
-Had bladder incontinence related to dementia;
-Check every two hours for incontinence;
-Wash, rinse and dry perineum.
Review of the resident’s annual MDS, dated [DATE], showed:
-Required supervision and assistance of one for personal hygiene;
-Always incontinent of bladder.
Observation on 1/24/19 at 12:04 P.M., showed Certified Nurse Aide (CNA) A and CNA E
provided care for the resident in the following manner:
-Both staff washed their hands and put on gloves.
-CNA A unfastened the resident’s brief.
-CNA E handed pre-moistened wipes to CNA A.
-CNA A cleansed the resident’s groin areas, but did not cleanse the resident’s genitals.
-Staff completed cleansing of the resident’s backside, then removed gloves and washed
their hands.
During an interview on 1/24/19 at 4:55 P.M., CNA A said staff should cleanse the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
resident’s genitals during incontinent care.
9. Review of Resident #25’s care plan, revised, 2/27/18, showed:- Incontinent of bowel and
bladder due to dementia;
– Check every two hours and as needed for incontinence;
– Monitor for signs and symptoms of UTI.
Review of the resident’s quarterly MDS, dated , 10/17/18, showed:
– Long and short term memory problems;
– Required extensive assistance of two staff for transfers, dressing and toilet use;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 1.24.19, at 3:51 P.M., showed:
– CNA C and CNA D transferred the resident into bed, pulled the resident’s pants and
unfastened his/her incontinent brief;
– CNA C wiped down each side of the resident’s groin with a different wipe;
– CNA C wiped down the middle perineal folds with one wipe;
– CNA C did not separate and thoroughly cleanse all the perineal folds;
– CNA D turned the resident on his/her side;
– CNA C wiped from front to back with fecal material;
– CNA C used a new wipe and wiped front to back;
– CNA C used the same area of the wipe and wiped up and down one side of the buttocks;
– CNA C used a new wipe and wiped down the other side of the buttocks;
– CNA C removed the wet incontinent brief and placed a clean one on the resident.
During an interview on 1/24/19, at 4:17 P.M., CNA C said:
– He/she should have separated and cleaned all areas of the skin where urine had touched;
– Should not wipe up and down the buttocks;
– Should wipe from front to back;
– Should not use the same area of the wipe to clean different areas of the skin.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
– Staff should separate and clean all areas of the skin where urine or feces has touched;
– Should not use the same area of the wipe to clean different areas of the skin;
– Staff should wipe from front to back;
– Staff should not wipe down the buttocks or up and down or back and forth on the
buttocks.

This deficiency is uncorrected. For further examples see Statement of Deficiency dated,
1/19/18.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, Licensed staff failed to assess the
resident’s change in condition when direct care staff reported they found an open area and
blood on the back of the resident’s left pant leg. This affected one of 26 sampled
residents (Resident #88). The facility census was 102.
1. Review of Resident #88’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/7/18, showed:
– Able to make daily decisions;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
– Required assistance of staff for transfers and bed mobility;
– Limited range of motion to both lower extremities
– Occasionally incontinent of bowel
– No pressure ulcers and no other skin issues.
Review of the resident’s care plan, revised on 1/14/19, showed:
– Resident at risk for skin integrity issues;
– Assess skin weekly and as needed;
– Use pressure relieving device on bed;
– When resident is out of bed, change position by toileting, uploading, shifting weight,
ambulating or return to bed to rest.
– Required one assist of staff with transfers.
– Limited range of motion with both lower extremities.
Observation and interview on 1/22/19 at 10:04 A.M., showed the resident sat in a recliner
chair with no pressure relieving device. The resident’s breakfast tray sat in front of
him/her untouched. The resident said he/she had sat there a while, he/she could reach the
breakfast tray but had not attempted to eat.
Observation and interview on 1/24/19 at 9:46 A.M., showed Certified Nurse Aid (CNA) F and
CNA G assisted the resident to the bathroom, When staff stood the resident, he/she had
what looked like blood stains on the back of his/her left pant leg slightly below the
buttocks. After the resident used the toilet CNA G stood to the resident’s side, reached
from behind and wiped the resident twice with a pre-moistened wipe. The resident yelled
out, Look out, my butt is raw, that hurts. Observation showed the resident had a circular
area, a little larger that a pea, just below the left gluteal fold (where the top backside
of the leg connects to the buttocks) that had the top layer of skin missing and a dried
reddish- brown substance around the area. CNA F wiped the reddish-brown substance from the
area and applied a skin barrier cream to the area.
During an interview on 1/25/19 at 1:20 P.M., CNA G said he/she reported to his\her charge
nurse (Licensed Practical Nurse (LPN) E on 1/24/19 that the resident had a place on
his/her left leg where the resident had been bleeding.
During an interview on 1/25/19 at 1:55 P.M., LPN E said:
– A CNA had reported to him/her yesterday that the resident’s leg was bleeding;
– The resident’s had [MEDICAL CONDITION] and his/her legs were very red;
– The wound nurse had a treatment for [REDACTED].
– He/she had not gone to the resident’s room and assessed the resident’s left gluteal fold
but did tell the wound nurse that staff reported the resident’s leg had bled.
Observation and interview on 1/25/19 at 2:20 P.M., showed LPN E and LPN C (the facility’s
wound care nurse) assisted the resident to the bathroom and looked at the resident’s open
area just below his/her left gluteal fold. LPN C asked the resident how long the had the
open area had been there and asked why the resident had not mentioned the open area to
him/her. The resident said it had been there a while and that he/she had told staff
his/her butt was raw and hurt.
During an interview on 1/25/19 at 2:45 P.M., the Director of Nurses said:
– She was unaware the resident had an open area on his/her left gluteal fold;
– If the top layer of skin was off, it would be a Stage II (a partial thickness loss of
skin layers that presents clinically as an abrasion, blister, or shallow crater) pressure
area.
– She would make sure the wound nurse assessed it, measured and documented it and
contacted the physician for treatment orders;
– When the direct care staff reported to the charge nurse the resident was bleeding on
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
his/her leg, the charge nurse should have went and assessed what had been reported to
him/her.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide and care
plan for restorative services (RS) to assist residents to attain or maintain their highest
practicable level of functioning for three residents (Residents #30, #43 and #102) out of
26 sampled residents who had limited range of motion (ROM) and/or other physical
limitations. The facility census was 102.
Review of the facility’s restorative program policy, last revised on 7/26/18, showed:
-The purpose of this policy is to provide direction and guidance to the clinical team to
assess and implement a plan of action for resident-specific care to maintain or improve
mobility with maximum practicable independence unless a reduction in mobility is
demonstrably unavoidable.
-Oversight and accountability for the program includes the medical director, director of
nurses (DON) and therapy (occupational and/or physical consults).
-The resident/representative will be included in the development of the restorative care
plan.
-Provision of necessary services, equipment, assistive devices and environmental
adaptations will be based on the assessment/evaluation.
-Care plan will address, but is not limited to, types of treatments, measurable
objectives, goals, interventions required for contractures, provides for increasing and
promotion of independence to the extent clinically possible for range of motion (ROM) and
mobility.
-Staff will be trained and competent in rehabilitative/restorative care.
-There will be sufficient staff to meet the needs of the program and resident care.
-Documentation to include attempts to implement and revise the care plan to address
changing needs, unavoidable decline and/or reduction in ROM and mobility, and addresses
potential complications.
1. Review of Resident #30’s therapy documentation, provided by facility staff, showed:
-Occupational therapy plan of care (evaluation only), dated 2/12/18, for a power
wheelchair safety test, with discharge plans to remain in facility with a functional
maintenance program;
-Occupational therapy plan of care (evaluation only), dated 6/14/18, for a power
wheelchair assessment, with discharge to current facility.
-Staff was unable to provide documentation for any restorative therapy received by the
resident.
Review of the resident’s care plan, last revised on 12/20/18, showed:
-[DIAGNOSES REDACTED].
-Had amputations of both lower extremities;
-Required extensive to total assistance for most care;
-Did not address limited use of his/her right extremity or any interventions to maintain
or improve the status of the right extremity.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
instrument completed by facility staff, dated 1/18/19, showed:
-Brief interview for mental status score of 0 (indicates severe cognitive impairment);
-Required total staff assistance for bed mobility, transfers, dressing and bathing;
-Able to eat and perform personal hygiene with supervision or cueing;
-Impaired ROM to one upper extremity and both lower extremities;
-Received no restorative or skilled therapy since the previous MDS assessment on 10/18/18;
-[DIAGNOSES REDACTED].
Observation on 1/22/19 at 11:55 A.M. showed the resident’s right hand contractured (a
muscle or tendon shortened or tightened to the point where it can not stretch normally)
and no brace, splint or other device in place.
Observation and interview on 1/24/19 at 12:04 P.M., showed, and Certified Nurse Aide (CNA)
E and CNA A said:
-The resident held his/her right hand out for CNA A to see.
-Resident said, Yeah, when CNA A asked if it hurt.
-CNA E said the resident’s fingernails had been cut.
-CNA A gently pulled the residents right fingers back to reveal a patch of white calloused
or flaky skin in the palm of his/her hand.
-The resident winced when staff pulled his/her fingers back and touched the area.
-CNA E said the resident would not allow staff to place a cloth between his/her fingers
and his/her hand.
-Both staff said the resident could use his/her left hand, but not the right one.
Review of the resident’s current electronic physician’s orders [REDACTED].
-Order date 5/16/18, order status active, may wear right carrot and elbow brace four hours
5-7 days a week. Resident does not always want to wear daily, but has agreed to 5-7 days.
During an interview on 1/25/19 at 10:27 A.M., the restorative assistant (RS) A said:
-The resident was not currently receiving RS, but was referred to RS by therapy earlier in
the year, it was overlooked, so was never started.
-RS A never received a functional maintenance plan (FMP) for the resident.
-The resident had limited ROM of one hand, and RS A agreed that the resident should be on
RS program.
-RS A was not sure who was responsible for making sure the RS received RS referrals and
FMP’s.
2. Review of Resident #43’s physical therapist progress and discharge summary, dated
8/22/18, showed:
-Goal met;
-Discharge instructions include bed cane rails for rolling, RS program for bilateral (both
sides) lower extremity (BLE) ROM to decrease contracture risk and trunk stability
activity.
-Signed by the physical therapist.
Staff provided no RS care program and staff was unable to provide documentation of any RS
care provided related to the 8/22/18 discharge instructions.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Required extensive to total assistance for bed mobility, personal hygiene, transfers,
toileting and bathing;
-No ROM impairment;
-Received physical and occupational therapy that started 10/30/18;
-No RS received;
-[DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
Review of the resident’s physical therapist progress and discharge summary, dated 12/5/18,
showed:
-Discharge instructions include RS program set up for BLE active ROM (AROM) and
rolling/re-positioning practice.
-Signed by the physical therapist.
Review of the resident’s RS care program, effective date 12/4/18, showed:
-A signature by the therapist, dated 12/4/18;
-A signature by the RS, dated 12/5/18;
-Goal to maintain mobility and generalized strength;
-Several exercises to meet the resident’s goals;
-Did not direct how often the RS should provide care.
Staff provided no documentation for RS care provided related to the 12/4/18 RS care
program.
Review of the resident’s care plan, last revised on 1/13/19, showed:
-Had a self care deficit related to a [DIAGNOSES REDACTED].
-Required two staff to re-position and transfer him/her;
-Required extensive assistance for personal hygiene;
-Had a urinary catheter (sterile tube inserted into the bladder to drain urine);
-Monitor/document/report to physician any changes, potential for improvement, reasons for
self-care deficit, expected course or declines in function;
-Did not address any RS plans or needs.
During an interview and observation on 1/24/19 at 4:24 P.M., observation showed, and, the
resident said:
-He/she had not received exercises due to someone was off for a funeral, or something like
that;
-Was supposed to start therapy again on Monday;
-Wanted exercises to help maintain the muscles in his/her arms and legs;
-Had not walked in years, due to fractures and injuries from five auto accidents and
[DIAGNOSES REDACTED];
-Resident showed that he/she could not move his/her legs.
Review of the resident’s current e-POS, dated 1/25/19, showed an active status order dated
12/9/18 for a referral to the RS program.
During an interview on 1/25/19 at 10:45 A.M., RS A said:
-The resident was supposed to receive RS, but the facility had not established a proper RS
program yet, so was not done.
-The resident did get up daily.
-He/she was the only RS and could not complete RS for all of the residents in the building
who needed it.
-A proper RS program had not been set up yet, so there was no documentation of any RS
provided.
3. Review of Resident #102’s quarterly MDS, dated , 12/11/18, showed:
– Cognitive skills intact;
– Required extensive assistance of one staff for bed mobility and dressing;
– Required extensive assistance of two staff for transfers;
– Dependent on one staff for toilet use;
– Lower extremity impaired on both sides;
– [DIAGNOSES REDACTED].
Review of the resident’s undated care plan, showed:
– The resident had [MEDICAL CONDITION] (paralysis of the legs and lower body) related to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
trauma;
– Interventions included assisting the resident with activities of daily living (ADL’s)
and locomotion as required. Encourage the resident to perform as much as possible of these
activities. Give medications as ordered. Pain management as needed;
– The care plan did not address RS or any exercises to maintain or enhance the resident’s
range of motion.
Review of the resident’s physician order [REDACTED].
– Start date: 11/16/18: an order for [REDACTED].>During an interview on 10:22 A.M., RS
A said:
– He/she was the only RS in the entire building;
– He/she had been in the position since July;
– Since (MONTH) he/she had really not been able to get an RS program started. Since
(MONTH) the facility has had several different upper management and it made it very
difficult to get an RS program started when there were so many changes with upper
management;
– He/she said the resident was not on RS but he/she believed they should.
4. During an interview on 1/28/19 at 11:45 A.M., the director of nurses (DON) said:
-There was no RS program in place.
-RS A was just doing basic things for residents at this time, possibly just weights and
vital signs.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interview and record review, the facility failed to assure staff
assured residents’ remained free of accident hazards when they failed to follow
manufacturer’s guidelines and facility’s Mechanical Lift policy during a mechanical lift
transfers for two sampled residents (Residents #9 and #70). Staff also did not use proper
techniques to reduce the possibility of accidents and injuries during the use of gait belt
(a safety device and mobility aid used to provide assistance during transfers, ambulation
or repositioning) transfers for Resident #25 and #88. The facility census was 102.
1. Review of the facility’s competency for Proper Use of a Gait Belt, provided by the
facility the facility Gait Belt policy, showed:
– Gait belts are used for safe transfers and ambulation;
– The gait belt should be tightly fastened around the upper chest;
– The gait belt should be applied snuggly to prevent slipping or riding up;
– Grab the gait belt on each side to assist the resident to stand.
2. Review of Resident #88’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/7/18, showed:
– Able to make daily decisions;
– Required assistance of staff for transfers.
Review of the resident’s care plan, revised on 1/14/19, showed:
– Resident is at high risk for falls;
– Required one assist of staff with transfers.
– Limited range of motion with both lower extremities.
Observation and interview on 1/24/19 at 9:46 A.M., showed Certified Nurse Aide (CNA) F and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
CNA G assisted the resident to the bathroom. CNA F placed the gait belt loosely around the
resident just under the residents breast. CNA F placed his/her right forearm just lower
than the resident’s armpit and grabbed the gait belt at the resident’s back, he/she
grabbed the back of the resident’s arm with his/her left hand. CNA G placed his/her left
forearm just below the resident’s armpit and grabbed the gait belt at the resident’s back.
He/she grabbed the resident’s arm with his/her other hand. When staff transferred the
resident his/her knees stayed bent, the gait belt rose up above the resident’s breasts,
staff’s forearms rose up underneath the resident’s armpits and the resident yelled, I
don’t like that up there now, it hurts.
During an interview on 1/24/19 at 4:25 P.M., CNA F said:
– He/she put gait belts above the resident’s waist;
– He/she tightened just tight enough so staff could still grip the gait belt;
– He/she put one arm under the resident’s arm and grab the gait belt at the resident’s
back on the side and with the other hand, grabbed the gait belt at the back of the
resident;
– The gait belt should not slide up, but if it did, he/she would re-tighten so he/she
could get a good grip.
3. Review of Resident #25’s care plan, revised, 2/27/18, showed:
– The resident had a self care performance deficit related to dementia;
– The resident required physical assistance when transferring.
Review of the Resident’s quarterly MDS, dated , 10/17/18, showed:
– Long and short term memory problems;
– Required extensive assistance of two staff for transfers and toilet use;
– No impairment to the upper and lower extremities;
– [DIAGNOSES REDACTED].
Observation on 1/24/19, at 3:51 P.M., showed:
– CNA C placed the gait belt around the resident’s upper chest, under the resident’s arm
pits and over the resident’s breasts;
– CNA C and CNA D placed one arm under the resident’s arm and grabbed the back of the gait
belt with the other hand;
– CNA C and CNA D transferred the resident from his/her wheelchair to the bed. After
incontinent care was provided, CNA C and CNA D sat the resident on the side of the bed;
– CNA C placed the gait belt loosely around the resident’s abdomen;
– CNA C and CNA D placed one arm under the resident’s arm and grabbed the back of the gait
belt with the other hand;
– The gait belt slid up in the front and up between the resident’s shoulder blades;
– CNA C and CNA D sat the resident in his/her wheelchair and removed the gait belt.
During an interview on 1/24/19, at 4:17 P.M., CNA C said:
– The gait belt should be placed below the resident’s breasts and below the abdomen;
– The gait belt should not slide up, it should have been readjusted;
– One hand should be on the back of the gait belt and on the side;
– Should not have placed my arm under the resident’s arm;
– The gait belt should not be over the resident’s breasts.
During an interview on 1/24/19, at 4:25 P.M., CNA D said:
– The gait belt should be placed around the resident’s waist;
– It should not slide up over the resident’s breasts or up in the back;
– Should have tightened the gait belt;
– Should have placed one hand on the front of the gait belt and one hand on the back of
the gait belt;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
– Should not have placed his/her arm under the resident’s arm.
4. During an interview on 1/28/19 at 11:45 A.M., the Director of Nurses said:
– Staff should place the gait belt around the resident’s waist;
– Staff should place their hands on each side of the resident, front and back;
– It is not acceptable to hold on to a resident’s arm or lift under a resident’s arm
during a transfer;
– Staff should not hook their arms under the resident’s arm and grab hold of the gait
belt.
5. Review of the facility’s policy related to the use of mechanical lifts for transfers,
revised 5/23/18, showed:
-The use of mechanical lifts requires a competent and skilled user and requires the use of
two employees to perform the lift safely.
-This policy is to provide general guidance for the use of mechanical lifts.
-Follow the manufacturer’s recommendations for specific mechanical lift equipment.
-Before engaging the sit-to-stand lift, make sure the resident’s knees are secure against
the knee pad, position the standing sling with the bottom edge on the resident’s lower
back, ensure rear casters are unlocked, the wheelchair wheels are locked, and the lift
legs are in the maximum open position.
Review of the user manual for the Invacare stand up patient lift (sit-to-stand lift)
provided by facility staff showed, in the warning box:
-Before lifting the resident, make sure the bottom edge of the standing sling is
positioned on the lower back of the resident and the resident’s arms are outside the
sling.
-Invacare does not recommend locking the rear casters of the stand up lift when lifting
and transferring an individual. Doing so could cause the lift to tip and endanger the
resident and assistants.
-Invacare recommends to that the rear casters be left unlocked during lifting and
transferring procedures to allow the stand up lift to stabilize itself when the resident
is initially lifted from and transferred to a bed, chair or any stationary object.
Review of the facility’s undated, Manufacturer’s Guideline for the Stand Up Mechanical
Lift, showed:
– The legs of the stand up lift must be in the maximum open position for optimum stability
and safety;
– Only close the legs of the lift as long as it takes to move through a narrow passage;
– Invacare does not recommend locking the rear castors of the stand up lift when lifting
and transferring an individual. doing so could cause the lift to tip and endanger the
resident and the assistants;
– Invacare does recommend that the rear castors remain unlocked during lifting and
transferring procedures to allow the stand up lift to stabilize itself when the patient is
initially lifted from and transferred to any stationary surface.
6. Review of Resident #70’s annual MDS, dated [DATE], showed:
-Required total assistance of two staff for transfers;
-Range of motion impairment of both upper extremities.
Review of the resident’s care plan for self care performance, last revised on 1/18/19,
showed:
-Required assistance of two staff for transfers;
-Use sit-to-stand for toileting.
Observation on 1/24/19 at 4:37 P.M., showed staff provided care in the following manner:
-CNA H was already in the resident’s room with gloves on.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-CNA A arrived with a sit-to-stand lift and washed hands and put on gloves.
-CNA A positioned the sit-to-stand in front of the resident’s wheelchair with lift legs
open, positioned the resident’s feet on the lift foot rest and locked the lift and
wheelchair wheels.
-CNA A then positioned the lift sling around the resident with the top edge of the sling
under each arm pit and the lower edge just below the breasts.
-Staff attached the lift sling to the lift arms.
-There was no strap to secure the resident’s legs and the resident’s legs did not rest
against the leg/knee support on the lift.
-CNA H raised the resident to a standing position with the lift.
-The lift sling pulled upward under the resident’s arm pits, which caused his/her
shoulders to also raise upward.
-Staff provided incontinent care and returned the resident to his/her wheelchair.
During an interview on 1/24/19 at 4:56 P.M., CNA A said:
-The sit-to-stand did not have a strap to secure the resident’s legs.
-Some have leg straps and others do not and he/she was not sure if the lift should have
had one or not.
-Staff should position the lift sling round the resident’s upper body beneath the breasts
and should be secure against the resident.
-The lift slings tend to ride up under the resident’s arms when they stand.
-He/she knew it could bruise the resident if the sling pulled against the arm pits.
-Staff should position residents so that their knees are against the lift knee support.
7. Review of Resident #9’s care plan, dated, 3/8/19, showed:
– The resident had a self care performance deficit related to [MEDICAL CONDITION] (a
progressive deteriorating nervous system disease that results in a gradual loss of muscle
function);
– The resident required physical assistance of two staff and Hoyer lift with transferring
or the sit to stand.
Review of the resident’s annual MDS, dated , 12/25/19, showed:
– Cognitive skills intact;
– Dependent on two staff for transfers and toilet use;
– [DIAGNOSES REDACTED].
Observation on 1/25/19, at 9:18 A.M., showed:
– CNA A opened the legs of the sit to stand lift and placed it around the resident’s
electric wheelchair and locked the back casters;
– CNA A and the Assistant Director of Nursing (ADON) fastened the lift pad around the
resident;
– CNA A raised the resident to a standing position, unlocked the brakes and moved to the
bathroom;
– CNA A closed the legs of the sit to go through the doorway, locked the casters and
lowered the resident onto the toilet;
– After CNA A and CNA B completed peri care, CNA A raised the resident up, unlocked the
casters and transferred the resident to his/her electric wheelchair;
– CNA A locked the casters and lowered the resident into his/her wheelchair;
– CNA A and CNA B unfastened the lift pad.
During an interview on 1/25/19, at 1:38 P.M., CNA A said:
– The casters should be locked on the the sit to stand lift when you raise or lower the
resident.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
– Staff should leave the castors unlocked when lifting or lowering the resident.
8. During an interview on 1/28/19 at 11:45 A.M., the director of nurses (DON) said:
-Was not sure if the sit-to-stand legs should be be opened or closed;
-Lift casters must be left unlocked during lifting procedures;
-Legs and knees should be against the leg support during transfers;
-The safety sling belt should be securely attached and the sling should not be under the
resident’s arms during the the sit-to-stand lift process.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
provided peri care and catheter (a sterile tube inserted into the urinary bladder to drain
urine) care in a manner to prevent a urinary tract infection [MEDICAL CONDITION] or the
possibility of a UTI which affected Residents #75, #80, #43 and #102. The facility census
was 102.
1. Review of the facility’s policy and procedure for Perineal Care, revised 9/6/17,
showed:
– To promote a sense of well-being and meets hygiene standards of care;
– Perform after incontinence of bowel, bladder, as needed and at least twice per shift for
residents wearing incontinence products;
– Includes cleansing of the perineum, from the pubis symphysus bone to the coccyx area;
Begin with the front genital area first and end with the coccyx area;
– Cleanest to dirtiest;
– Manipulate and thoroughly cleanse all perineal skin areas and inner thighs.
Review of the facility’s policy and procedure for Catheter Care, revised 5/1/17, showed:
– Catheter care is performed at least twice daily;
– Catheter associated urinary tract infections is the most common adverse event associated
with an indwelling catheter;
– For residents with a catheter, perform peri care first and with incontinence of bowels;
– With a clean cloth or wipe, firmly grasp the catheter tubing nearest to the insertion
site to prevent movement or accidental dislodgement and clean around the insertion site;
– With a clean cloth or wipe, wipe down the catheter from the insertion site approximately
six inches;
– Secure the catheter to leg with a device or tape.
2. Review of Resident # 75’s medical record showed a laboratory urinalysis report, dated
11/14/18, showed bacteria consistent with a UTI.
Review of the resident’s care plan, revised on 12/3/18, showed:
– At risk for developing UTI;
– Change drainage bag per policy;
– Check tubing for kinks each shift;
– Empty and record output each shift.
– Provide catheter care daily.
Review of the resident’s Minimum Data Set (MDS|), a federally mandated assessment
instrument completed by facility staff, dated 1/9/19/ showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
– Able to make daily decisions without difficulty;
– Dependent on staff for toilet use and personal hygiene;
– Catheter.
– [DIAGNOSES REDACTED].
Observation on 1/24/19 at 11:02 A.M., showed the resident lay in bed, Certified Nurse Aide
(CNA) G assisted Licensed Practical Nurse (LPN) C with a wound treatment. Following the
wound treatment LPN C removed his/her gloves, washed hands and put on new gloves. LPN C
removed the split 4X4 dressing from around the suprapubic catheter and cleaned the
insertion site. LPN C retrieved a clean wipe, grasped the catheter tubing approximately
four inches from the insertion site and wiped the catheter tubing up towards the insertion
site, then placed a clean split 4X4 around the tubing at the insertions site. CNA F
entered to assist CNA G finish peri and catheter care and transfer the resident to his/her
chair. CNA F rolled the resident towards CNA G and pulled the brief from under the
resident, placed a clean brief under the resident and rubbed barrier cream on the
resident’s lower perineal skin without first cleaning the area. Staff laid the resident on
his/her back and CNA G used two premoistened wiped and wiped one time down each groin.
Staff pulled the resident’s brief up between his/her legs and fastened it. CNA G placed a
paper towel on the floor and put a graduate on top of the towel, pulled the drain spout
out of the urinary drainage bag holder, drained the urine into the graduate, wiped the
spout off with a premoistened wipe and placed the drain spout back up in the holder.
During an interview on 1/24/19 at 3:40 P.M., LPN C said:
– He/she should clean the catheter tubing from the insertion site downward about four
inches.
During an interview on 1/24/19 at 4:25 P.M., CNA F said:
– Staff should provide pericare even if the resident had a suprapubic catheter;
– Staff should clean all perineal folds;
– He/she did not clean the resident before he/she applied barrier cream.
During an interview on 1/25/19 at 10:40 A.M., CNA G said:
– He/she had always wiped the drain spout with a premoistened wipe, he/she did not know
anything else he/she should use;
– The resident sweat, so he/she needed to wipe down each groin, if the resident had
discharge, then he/she cleaned the perineal skin folds.
3. Review of Resident # 80’s care plan, revised 6/4/18, showed:
– The resident needed staff assist with personal hygiene;
– The resident needed assist to wipe self;
– Staff should provide incontinence care as needed.
Review of the resident’s MDS, dated [DATE], showed:
– Unable to make daily decisions;
– Required extensive assist of staff with toilet use and personal hygiene.
Review of the resident’s (MONTH) 2019, POS, showed a physician order [REDACTED].
Observation and interview on 1/28/19 at 9:34 A.M., the resident sat in his/her wheelchair
yelling out, Come on, come on, I got to pee. CNA F assisted the resident to transfer to
the toilet. CNA F said the resident’s brief was wet. The resident urinated and had a small
bowel movement in the toilet. CNA F assisted the resident to stand to the side of the
resident, reached forward and wiped from the resident’s rectal area to the coccyx. He/she
did not clean the resident’s buttocks or inner thighs. CNA F then stepped in front of the
resident and without manipulating the perineal skin folds, wiped once front to back.
During an interview on 1/28/19 at 1:25 P.M., CNA F said:
– Sometimes the resident tried to wipe him/her self;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
– He/she should separate and clean all the perineal folds and skin that urine had touched.
4. Review of Resident #43’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Required extensive assistance for bed mobility and personal hygiene;
-Had a urinary catheter.
Review of the resident’s urine culture and sensitivity (lab to determine presence of
bacteria and best medications to treat with), collected 12/21/18, showed:
-Presence of the bacteria P. stuartii (a common bacteria that causes infection in
residents with long-term catheters) in an amount suggesting the possibility of a UTI;
-Presence of the bacteria M. morganii (found in the intestinal tract and associated with
UTI’s) in an amount suggesting the possibility of a UTI.
Review of the resident’s care plan, last revised on 1/13/19, showed:
-Had a urinary catheter;
-Provide catheter care each shift;
-Had a UTI 11/12/18 and received intravenous antibiotic therapy;
-Monitor for signs and symptoms of a UTI.
Review of the resident’s current electronic physician order [REDACTED].
Observation and interview on 1/24/19 at 9:22 A.M., showed LPN C said and did the
following:
-An unpleasant odor came from the resident’s catheter bag.
-LPN C said the resident currently received an antibiotic for a UTI.
-LPN C washed his/her hands, put on gloves emptied urine from the catheter drainage bag,
and replaced the catheter bag drain spout in the holder.
-He/she did not cleanse the drain spout before or after he/she emptied the bag.
-LPN C then removed his/her gloves and washed his/her hands.
During an interview on 1/25/19 at 8:42 A.M., LPN C said he/she was unaware that staff
should cleanse the catheter bag drain spout before or after they emptied the bag.
Observation on 1/24/19 at 3:59 P.M. showed CNA A emptied the resident’s catheter in the
following manner:
-Washed hands and put on gloves;
-Set a urinal on the floor and emptied urine from the catheter drainage bag into the
urinal;
-The urine had a strong, unpleasant odor;
-Cleansed the catheter bag drain spout with a pre-moistened wipe and returned it to the
spout holder;
-Emptied the urinal in the bathroom, removed his/her gloves and washed his/her hands.
During an interview on 1/24/19 at 4:55 P.M., CNA A said he/she:
-Always used a pre-moistened wipe to cleanse the catheter bag spout;
-Had not been told to use an alcohol wipe.
5. Review of Resident #102’s quarterly MDS, dated , 12/11/18, showed:
– Cognitive skills intact;
– Required extensive assistance of one staff for bed mobility and dressing;
– Required extensive assistance of two staff for transfers;
– Dependent on one staff for toilet use;
– Lower extremities impaired on both sides;
– Had a Foley catheter.
Review of the resident’s urinalysis, (UA, a test to analyze urine contents) dated 1/23/19,
showed:
– the presence of bacteria indicative of a possible UTI.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
Review of the resident’s UA with C & S, dated, 1/26/19, showed:
– The presence of organisms indicative of a possible UTI.
Review of the resident’s undated care plan, showed:
– The resident had an indwelling catheter;
– Position catheter bag and tubing below the level of the bladder;
– Change catheter per policy/physician’s orders [REDACTED].>- Monitor and document
intake and output;
– Check tubing for kinks.
Observation on 1/24/19, at 10:01 A.M., showed:
– After LPN C provided wound care to the resident’s sacrum (area at the base of the spinal
column), he/she reached between the resident’s legs and wiped from front to back;
– He/she placed a clean incontinent brief under the resident;
– LPN C turned the resident onto his/her back, removed the old incontinent brief and
pulled the clean one through;
– The resident did not have a leg strap to secure the catheter tubing;
– LPN C wiped down each side of the groin with a different wipe;
– He/she used the same area of the wipe and cleaned the perineal fold and wiped the
catheter tubing at the insertion site and did not anchor the tubing;
– LPN C fastened the clean incontinent brief;
– LPN C did not clean all the perineal folds and did not clean down the catheter tubing.
During an interview on 1/25/19, at 10:13 A.M., LPN C said:
– He/she usually left the catheter care for the nurse’s to do;
– He/she should have used a new wipe and cleaned all the areas of the skin.
Observation on 1/25/19, at 11:20 A.M., showed:
– CNA B placed the urinal directly on the floor;
– CNA B opened the spout and emptied 150 ml. of dark yellow urine and replaced the spout;
– CNA B did not clean the spout;
– The resident did not have a leg strap to secure the catheter tubing;
– CNA B wiped down the tubing then used the same area of the wipe and wiped down the
tubing again and used the same area of the wipe and cleaned around the perineal folds;
– CNA B used a new wipe and cleaned down each side of the resident’s groin with a
different wipe each time;
– CNA B fastened the incontinent brief;
– CNA B and CNA E transferred the resident into his/her wheelchair and the dignity bag
rested on the floor and dragged on the floor as the resident propelled him/herself down
the hallway.
6. During an interview on 1/25/19, at 1:46 P.M., CNA B said:
– He/she should have placed the urinal on a clean barrier;
– He/she was not for sure if the spout was supposed to have been cleaned;
– The dignity bag should not rest or be dragged on the floor;
– Should not use the same area of the wipe to clean different areas of the skin;
– Should clean all areas of the skin.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
– Staff should not use the same area of the wipe to clean different areas of the skin;
– Staff should provide complete peri care during catheter care;
– The resident should have a leg strap and it should be documented and care planned if the
resident refused the leg strap;
– The dignity bag should not rest on the floor or be dragged on the floor.
– Staff should clean any area urine or feces touched when they provide peri care;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
– Staff should grasp the catheter tubing at the insertion site and clean down (away from
the body) the tubing at least four inches.
-Staff should cleanse the catheter drainage bag spout with alcohol when they drain the
urine.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to assure staff
provided proper respiratory care when staff failed to properly clean oxygen concentrator
filters. This affected Residents #75, #80, #70 and #82. The facility census was 102.
1. Review of the facility’s policy for Oxygen Therapy Using Concentrators, revised
11/9/18, showed filters and machines are to be cleaned once a week.
2. Review of Resident #80’s care plan, revised 5/25/18, did not address and breathing
problems or oxygen use.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/28/18, showed:
– Both short and long term memory problems;
– Required assistance of staff with all activity of daily living.
Staff did not code the MDS with any breathing problems or oxygen therapy.
Review of the resident’s (MONTH) 2019 physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– Order for continuous oxygen at two liters via nasal canula to keep oxygen saturation
level above 90 %.
Observation at varying times on all days of the survey 1/22/19, 1/23/19, 1/24/19, 1/25/19
and 1/28/19 showed the resident used both a portable oxygen tank and his/her oxygen
concentrator in his/her room. The oxygen concentrator had two places for foam filters. The
empty place for the filter had gray dust covering the area that wiped away with a finger.
The other space held a foam filter that was heavily covered with gray lint and dust that
could be scraped off with a fingernail.
3. Review of Resident #75’s January, 2019, POS, showed:
– [DIAGNOSES REDACTED].
– Order for oxygen at two liters via nasal canula to keep oxygen saturation levels at 92%
or greater.
Review of the resident’s plan of care, revised 1/2/19, showed:
– Check saturation level every shift;
– Monitor symptoms of respiratory distress;
– Promote lung expansion and improve air exchange by positioning with proper body
alignment so that he/she does not slide down in bed.
Review of the resident’s MDS, dated [DATE], showed :
– Ale to make daily decisions without difficulty;
– Dependent on staff for all ADLs;
– Oxygen therapy.
Observation at varying times on all days of the survey 1/22/19, 1/23/19, 1/24/19, 1/25/19
and 1/28/19 showed the resident used his/her oxygen concentrator in his/her room. The
oxygen concentrator had two places for foam filters. The empty place for the filter had
gray dust covering the area that wiped away with a finger. The other space held a foam

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
filter that was heavily covered with gray lint and dust that could be scraped off with a
fingernail.
During an interview on 1/25/19 at 4:25 P.M. Certified Nurse Aide (CNA ) G said he/she did
not clean the filters or replace the oxygen tubing.
4. Review of Resident #70’s annual MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Received oxygen therapy.
Review of the resident’s care plan related to oxygen therapy, last revised on 1/18/19,
showed:
-On oxygen therapy related to [MEDICAL CONDITION] and [MEDICAL CONDITION];
-Did not address cleaning the oxygen concentrator filters.
Observations on 1/22/19 at 3:31 P.M. and 1/24/19 at 10:12 A.M. showed the resident
received oxygen and both oxygen concentrator filters covered with gray lent.
Review of the resident’s current electronic physician order [REDACTED].
-Oxygen at 2 liters/minute per nasal cannula as needed to keep oxygen saturations above
90%;
-Clean filters every Thursday on day shift.
5. Review of Resident #82’s care plan, last revised on 7/9/18, showed:
-Had [MEDICAL CONDITION];
-Will be free of signs and symptoms of respiratory infections through next review date;
-Received oxygen therapy;
-Did not address cleaning the oxygen concentrator filters.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Received oxygen therapy.
Observation on 1/22/19 at 9:40 A.M. and 1/24/19 at 8:30 A.M., showed:
-Resident in his/her room with oxygen on.
-The oxygen concentrator filer missing from the left side of the concentrator, and the
filter on the right side covered in gray lent.
Review of the resident’s current e-POS, dated 1/25/19, showed:
-Oxygen at 2 liters/nasal cannula continuously for [MEDICAL CONDITION];
-Did not address cleaning of oxygen concentrator filters.
6. During an interview on 1/28/19 at 10:28 A.M., the Assistant Director of Nurses said:
– Filters are to be cleaned every Wednesday by central supply staff:
– This is at the same time he/she should put out and date all the new tubing as well as
date the bags the tubing is placed into;
– Central supply staff had been educated about this process.

F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff consistently and
accurately documented pain medication administration and failed to ensure the resident’s
pain medication supply did not run out for one out of 26 sampled residents (Resident #47).
The facility census was 102.
Review of the facility’s policy related to medication administration, last revised on
12/14/17, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
-Medications will be charted when given.
-Narcotics will be signed out when given.
-PRN (medications given as needed) will have a reason documented for giving and the
effectiveness of the drug.
-Documentation of medications will follow accepted standards of nursing practice.
1. Review of Resident #47’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/25/18, showed:
-Required extensive to total staff assistance for care;
-Received no scheduled pain medication;
-Received PRN pain medication and non-medication pain interventions;
-Voiced pain;
-Exhibited indicators of pain 1-2 days out of 5;
-Received opioids (a narcotic pain medication) 4 out of 7 days.
Review of the resident’s care plan, last revised on 11/14/18, showed:
-On pain medication for [MEDICAL CONDITION] (infection beneath the skin surface) and left
ankle fracture;
-Administer pain medication as ordered;
-Review for pain medication efficacy, assess whether pain intensity is acceptable to
resident;
-Review to determine if therapeutic regimen is followed but pain control is not adequate
and changes are required.
Review of the resident’s physician order [REDACTED].
-[MEDICATION NAME] 2 milligrams (mg), give 2-4 mg every 3 hours as needed for pain;
-[MEDICATION NAME] 5-325 mg every 6 hours as needed for pain.
Review of the resident’s controlled substance proof of use sheets for his/her [MEDICATION
NAME] 2 milligrams (mg) tablets ([MEDICATION NAME], a narcotic pain medication), received
1/2/19, showed:
-Each of two sheets directed to take 1-2 tablets by mouth every 3 hours as needed for
pain;
-Each sheet showed 30 tablets dispensed (total of 60 tablets), both on 1/2/19;
-Six doses of two tablets administered on 1/2;
-Five doses of two tablets administered on 1/3;
-Five doses of two tablets administered on 1/4;
-Four doses of two tablets administered on 1/5;
-Five doses of two tablets administered on 1/6;
-Five doses of two tablets administered on 1/7 at 6:30 P.M., which completed the 60
tablets dispensed;
-Important: The nurse who signs this record must also sign the separate medication
administration record for each dose given.
Review of the resident’s medication administration record (MAR) for the dates of
1/2/19-1/7/19, showed:
-[MEDICATION NAME] 2 mg, give 2-4 mg every three hours as needed for pain;
-One dose documented as administered on 1/2 (unable to tell if one tablet or two);
-Two doses documented as administered on 1/3 (unable to tell if one tablet or two);
-No doses documented as administered on 1/4/19-1/7/19 (unable to tell if one tablet or
two).
Review of the resident’s controlled substances proof of use sheet for [MEDICATION
NAME]/[MEDICATION NAME] 5-325 (a narcotic pain medication), dated as received 1/2/19,
showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
-Take 1-2 tablets by mouth every 6 hours as needed for pain,
-One sheet of 20 tablets dispensed;
-One dose administered at 8:00 P.M. on 1/7;
-Three doses administered on 1/8;
-One dose administered on 1/9 at 9:00 A.M.;
-Two doses administered on 1/15 at 10:00 A.M. and 8:00 P.M.
Review of the resident’s controlled substance proof of use sheets for his/her [MEDICATION
NAME] 2 mg tablets, with no receipt dates documented, showed:
-Each of two sheets directed to take 1-2 tablets by mouth every 3 hours as needed for
pain;
-Each sheet showed 30 tablets dispensed (total of 60);
-No documentation to show any [MEDICATION NAME] 2 mg tablets were available after the 1/7
dose administered at 6:30 P.M. and the next dose administered on 1/9 at 12:00 noon.
-No doses documented as administered on 1/8;
-Three doses of two tablets administered on 1/9 starting at noon;
-Seven doses of two tablets administered on 1/10;
-Three doses of two tablets administered on 1/11;
-Six doses of two tablets administered on 1/12;
-Five doses of two tablets administered on 1/13;
-Five doses of two tablets administered on 1/14;
-One dose of two tablets administered on 1/15 at 2400 (midnight), which completed the 60
tablets dispensed;
-Important: The nurse who signs this record must also sign the separate medication
administration record for each dose given.
Review of the resident’s medication administration record (MAR) for the dates of
1/8/19-1/15/19, showed:
-[MEDICATION NAME] 2 mg, give 2-4 mg every three hours as needed for pain;
-No doses documented as administered 1/8/19-1/11/19;
-Two doses documented as administered on 1/12 (unable to tell if one tablet or two);
-Three doses documented as administered on 1/13 (unable to tell if one tablet or two;
-Three doses documented as administered on 1/14 (unable to tell if one tablet or two;
-No doses documented as administered on 1/15.
Review of the resident’s controlled substance proof of use sheets for his/her [MEDICATION
NAME] 2 mg tablets, received 1/16/19, showed:
-Each of three sheets directed to take 1-2 tablets by mouth every 3 hours as needed for
pain;
-Each sheet showed 30 tablets dispensed (total of 90 tablets);
-Six doses of two tablets documented as administered, with the first dose administered at
1:15 A.M. on 1/16, and no documentation of the availability of any [MEDICATION NAME] for
the remainder of 1/15 from midnight until the following day of 1/16 ;
-Six doses of two tablets documented as administered on 1/17;
-Six doses of two tablets documented as administered on 1/18;
-Six doses of two tablets documented as administered on 1/19;
-Five doses of two tablets documented as administered on 1/20;
-Five doses of two tablets documented as administered on 1/21;
-Five doses of two tablets documented as administered on 1/22;
-Six doses of two tablets documented as administered on 1/23, with the last dose
administered at 6:45 P.M.
-Important: The nurse who signs this record must also sign the separate medication
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
administration record for each dose given.
Review of the resident’s medication administration record (MAR) for the dates of
1/16/19-1/23/19, showed:
-[MEDICATION NAME] 2 mg, give 2-4 mg every three hours as needed for pain;
-One dose documented as administered on 1/16 (unable to tell if one or two tablets);
-One dose documented as administered on 1/17 (unable to tell if one or two tablets);
-One dose documented as administered on 1/18 (unable to tell if one or two tablets);
-Two doses documented as administered on 1/19 (unable to tell if one or two tablets);
-No doses documented as administered on 1/20;
-Four doses documented as administered on 1/21 (unable to tell if one or two tablets);
-Two doses documented as administered on 1/22 (unable to tell if one or two tablets);
-One dose documented as administered on 1/23 (unable to tell if one or two tablets).
Review of the resident’s controlled substance proof of use sheets for his/her [MEDICATION
NAME] 2 mg tablets, received 1/27/19, showed:
-Directed to take 1-2 tablets by mouth every 3 hours as needed for pain;
-Received 30 tablets;
-Staff signed out the first dose on 1/27 at 6:15 A.M.;
-Staff could not provide documentation that the resident’s [MEDICATION NAME] was available
from 1/23 at 6:45 P.M. until 1/27 at 6:15 A.M.
Review of the resident’s MAR for 1/24/19 and 1/25/19 showed no documentation that the
resident received any [MEDICATION NAME] (MAR was printed for surveyor on 1/25/19 at 11:12
A.M.)
Review of the resident’s controlled substances proof of use sheet for [MEDICATION
NAME]/[MEDICATION NAME] 5-325 (a narcotic pain medication), dated as received 1/2/19,
showed:
-Take 1-2 tablets by mouth every 6 hours as needed for pain;
-Received two doses on 1/24;
-Received one dose on 1/25.
Review of the resident’s (MONTH) 2019 MAR for [MEDICATION NAME]/[MEDICATION NAME] 5-325 mg
showed:
-Take one by mouth every 6 hours as needed for pain;
-One dose was documented as administered on 1/24/19.
Review of the resident’s nursing progress notes from 1/2/19 through 1/25/19 showed no
documentation where staff contacted the physician or pharmacy related to not having the
resident’s [MEDICATION NAME] or related to obtaining a script for it.
During an interview on 1/22/19 at 10:07 A.M., the resident said:
-Staff ran out of her pain medication about every eight to nine days, then it took two to
three days to get more.
-He/she had to deal with pain without the medication, and also went through withdrawal,
which was awful.
-It happens frequently, and staff should figure out a way to prevent this from occurring.
During a group resident interview on 1/24/19 at 1:31 P.M., attended by ten residents,
residents said:
– The majority of the group said staff tell them they are out of their pain medication and
then do not get their medication, sometimes 4-5 days late.
-Staff re-order when the medication is out.
-This has been discussed at previous resident council meetings.
During an interview on 1/28/19 at 11:43 A.M. and 11:45 A.M., the Director of Nursing (DON)
said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
-Residents received a 14 day supply of pain medications.
-Staff should re-order the pain medication when there are five to seven days of medication
remaining so they don’t run out.
-DON was not aware of residents running out of pain medication.
-Staff should follow physicians’ orders.
During an interview on 1/28/19 at 1:11 P.M., Licensed Practical Nurse (LPN) H said:
-Residents have run out of medications and staff calls the pharmacy and are told they have
to have a signed script.
-They then call the physician and put a note in the nurses’ progress notes.
-They replace the scheduled medication with a PRN medication, if needed.
During an interview on 1/28/19 at 2:45 P.M. the Assistant Director of Nursing (ADON) said:
-Resident will not go 7 hours without getting his/her [MEDICATION NAME].
-Could not find one recent [MEDICATION NAME] narcotic sign out sheet for (MONTH) 2019.
During a phone interview on 1/31/19 at 1:12 P.M., LPN A said:
-Pain medications should be documented on the e-MAR and in the narcotic book (controlled
substance proof of use sheet) to ensure a correct medication count.
-The e-MAR and narcotic book should match as far as date and time administered.
-Residents sometimes ran out of medications, but staff had access to the e-kit (emergency
supply of medications) until the pharmacy delivered the needed medication.
-If a resident did not receive a medication, the it was usually due to the time required
to fill out insurance paperwork and/or obtaining a written script.
-If a resident takes a PRN pain medication on a routine basis, then staff should contact
the physician to obtain an order to schedule the medication to obtain better pain control
for the resident.

F 0732

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Post nurse staffing information every day.

Based on observation, interview, and record review, the facility failed to post the nurse
staffing data in a prominent place readily accessible to all residents and visitors on a
daily basis at the beginning of each shift. The facility census was 102.
1. Observations on 1/25/19 and 1/28/19 showed incomplete nurse staffing data forms posted
in a plastic sleeve on a wall to the right of the front entry to the facility. There was
no nurse staffing data posted on the 500 hall locked unit. Staff had not completely filled
out the forms according to staff actually working, rather they listed the amount of staff
scheduled for the entire day (24 hour period) and did not list the census.
During interviews on 1/28/19 at 2:45 P.M.,Licensed Practical Nurse (LPN) F said the nurse
staffing sheet was always kept at Center Court. At 2:55 P.M., LPN G said the only posted
staffing he/she knew about at Center Court as the notebook where staff looked to find
their assigned work areas. At 3:05 P.M., the Director of Nurses said the Nursing Staff
Scheduler (NSS) took care of posting the nurse staffing form but she did not know where if
was posted. At 3:46 P.M., the NSS said he/she filled out the form each day how many of
each staff were scheduled for each shift. He/She had not entered the census information on
the form. The form was not filled out at the beginning of each shift with the number of
nursing staff that showed up to work each shift. He/she said there was only one staffing
sheet for the entire building. There was not a nurse staffing form posted on the 500 hall
locked unit.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0732

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

Based on observations, interviews and record review, the facility failed to ensure the
intravenous (IV) emergency medication and supplies kit (E-Kit) was locked, current and not
expired. The facility census was 102.
1. Review of the facility’s storage and expiration of medications, biologicals, syringes
and needles policy, revised, on 10/31/16, showed, in part:
– The facility should ensure that infusion therapy products and supplies are stored
separately from other medications and biologicals;
– Facility should request that Pharmacy perform a routine nursing unit inspection for each
nursing station in facility to assist facility in complying with its obligations pursuant
to Applicable Law relating to the proper storage, labeling, security and accountability of
medications and biologicals.
2. Observation on 1/28/19, at 10:40 A.M., of the medication room for the 100, 200, and 300
halls, showed:
– In the cabinet underneath sink an opened toolbox used as IV E-kit and had no locks on
it;
– It expired 3/2018 and had several 1000 milliliters of various types of IV fluids which
were expired.
Review of the facility’s consultant pharmacist summary, dated, January, 2019, showed, in
part:
– Medications in the emergency supply are in date, ordered/re-ordered appropriately, and
sealed (if applicable); evaluation showed no irregularities observed.
During an interview on 1/28/19, at 11:43 A.M., the Assistant Director of Nursing (ADON)
said:
– The pharmacist consultant checked the medication rooms and medication carts for expired
medications;
– She destroys the expired medications with another Certified Medication Technician (CMT)
and if it’s a narcotic, destroyed it with another nurse;
– She had not destroyed any medications in five weeks;
– She was not aware of an IV E-kit that was opened and expired 3/18;
– The pharmacist was in the facility last week;
– She was not for sure if the pharmacist checked the medication rooms or medication carts.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record reviews, the facility failed to provide
documentation that the consultant pharmacist (PharmD) performed monthly medication regimen
recommendations (MRR) for the month of (MONTH) (YEAR). The facility failed to provide

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
documentation that the resident’s physicians were provided with MRR in a timely manner and
did not provide the physician’s response. The facility did not ensure that as needed (PRN)
orders for [MEDICAL CONDITION] medications were reviewed and reordered every 14 days by
the physician. The facility did not implement recommendations for a gradual dose reduction
(GDR) for a [MEDICAL CONDITION] medication. This affected (Residents #75, #28, #45, #55,
#103, #81 ). The facility census was 102.
Review of the facility’s (MONTH) 2019, Consultant Pharmacist Summary, showed:
– Widespread issues observed with previous MRR have been acted upon appropriately.
1. Review of the following Resident’s January, 2019 physician’s orders [REDACTED].
– Resident # 75’s [MEDICATION NAME] HCI 25 mg every six hours as needed (PRN) for anxiety
ordered 12/28/18;
– [MEDICATION NAME] (Antianxiety) 0.5 milligram (mg) tablet three times a day ordered
12/27/18;
– [MEDICATION NAME] Capsule (Hypnotic) 15 mg at bedtime, ordered 12/28/18;
– [MEDICATION NAME] HCI (Hypnotic) 50 mg at bedtime, ordered 12/28/18.
– Resident # 28’s [MEDICATION NAME] XL (Antidepressant) 300 mg daily, ordered 10/29/18.
Resident #45’s [MEDICATION NAME] (Antianxiety) 5 mg three times a day, ordered 10/29/18;
– Duloxetine (Antidepressant) 60 mg daily, ordered 10/24/18.
During an interview on 1/28/19 at 12:47 P.M., the Assistant Director of Nurses (ADON)
said;
– There were no record the consultant pharmacist monthly review for (MONTH) (YEAR);
– She personally handed the consultant pharmacist’s monthly review and recommendations to
all but four of the residents’ physician at the quality assurance meeting;
– She made changes per the pharmacist recommendations that did not require a physician’s
authorization to make the change;
– Often times physician responses did not get carried through and documented by the
nursing staff.
2. Review of Resident #103’s medical record showed:
– A pharmacy consultation report dated 8/7/18 showed the resident was receiving the
following [MEDICAL CONDITION] medications: [REDACTED]
– [MEDICATION NAME] (medication used to treat anxiety) 10 milligrams (mg) twice daily;
– Depekene (medication used to treat dementia with behaviors) 250mg at bedtime;
– [MEDICATION NAME] (medication used to treat dementia with behaviors) 15mg;
– [MEDICATION NAME] (a medication used to treat depression) orally disintegrating tablet
(ODT) 30mg once daily;
– The recommendations the following: consider a GDR for resident’s [MEDICATION NAME] from
15mg to 10mg and review the resident’s Buspbar, [MEDICATION NAME], and [MEDICATION NAME]
for GDR at this time;
– The report was marked that the physician accepted the recommendations and was signed by
the physician.
Review of the Resident’s physician orders [REDACTED].
– [MEDICATION NAME] HCL 10mg, give one tablet orally two times a day;
– Depekene 250mg,give one capsule by mouth at bedtime;
– [MEDICATION NAME] ([MEDICATION NAME]) 15mg, give one time daily;
– [MEDICATION NAME] ([MEDICATION NAME])[MEDICATION NAME], give one tablet orally at
bedtime.
Review of the resident’s medical record did not show that the recommendation for the GDR
had been implemented or that the recommendations to review the other medications for a GDR
had been followed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
During an interview on 01/28/19 at 10:55 A.M. the Assistant Director of Nursing (ADON)
said The old DON would print off recommendations, hand them to her, then she would do the
orders. She did not see Resident #103’s (MONTH) pharmacist consultation report. The GDR
did not get done. She let’s the psychiatrist know of the changes and if there have been
any changes in the resident’s behavior. The psychiatrist is who would have reviewed the
other medication during his next visit for GDR. There have not been changes to the
resident’s medication.
– Record review showed the psychiatrist did not see the resident in (MONTH) or September.
2. Review of Resident #55’s medical record showed:
– Date of admission 1/16/18
– 12/4/2018 15:50 Pharmacy Consultant Note dated 12/4/18 that state See report for any
noted irregularities and/or recommendations;
– No consultation report was found in the resident’s medical record.
3. Review of Resident #81’s medical record showed:
– Date of admission 8/31/16;
– 1/9/19 Pharmacy Consultation Report showed a request to clarify the resident’s maximum
dosage for [MEDICATION NAME];
– The report did not contain any physician’s response or documented acknowledgement by
facility staff of receipt of the clarification request.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
administered medications with an error rate of less than five percent. Facility staff made
seven errors out of 25 opportunities for error, resulting in an error rate of 28%. This
affected six residents (Residents #22, #100, #72, #3). The facility census was 102.
1. Review of the facility’s policy related to administering nasal sprays, revised 7/24/18,
showed:
-Ask resident to clear nasal passages by gently blowing nose prior to administration;
-Assist resident to tilt head slightly upwards;
-Using a gloved finger, or direct the resident to occlude the opposite nostril, administer
the spray into the nostril.
-Direct tip of the sprayer toward midline of nose so mist will flow to the back of the
nasal cavity rather than dripping down the throat.
-Ask resident to inhale, breathing in through the nose, and squeeze the atomizer (device
for emitting a fine spray) quickly and firmly while releasing the occluded nostril.
-Repeat procedure in other nostril, if indicated.
-Instruct resident to keep head tilted back several minutes until medication is dispersed.
2. Review of Resident #22’s current electronic physician order [REDACTED].
Observation on 1/24/19 at 10:14 A.M., showed Certified Medication Technician (CMT) A
administered the resident’s [MEDICATION NAME] nasal spray (a steroid used to treat
allergies and inflammation) in the following manner:
-Shook the medication bottle and handed it to the resident;
-The resident administered two consecutive sprays into the right nostril, without
occluding the left nostril or waiting between sprays;
-The resident repeated the same procedure to the left nostril;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
-CMT A did not provide instruction to the resident prior to administration related to
occluding the opposite nostril or waiting between sprays to allow medication absorption.
During an interview on 1/24/19 at 10:55 A.M., CMT A said:
-He/she did not know one nostril should be occluded when the medication was administered
to the opposite nostril;
-Should wait a couple minutes before a second spray is administered, if two sprays are
ordered;
-He/she did not instruct the resident about these procedures prior to administration of
the medication.
2. Review of the facility’s medication administration policy, revised 12/14/17, showed, in
part:
– The purpose of this policy is to provide guidelines for general medication
administration to be provided by personnel recognized as legally able to administer;
– Observe the five rights in giving each medication: the right resident, the right time,
the right medicine, the right dose, and the right route;
– Read medication label three times before administering medication, first, when comparing
label to Medication Administration Record [REDACTED].
3. Review of Resident #72’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/5/18, showed:
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED].
Observation and interview on 1/25/19, at 8:46 A.M., showed:
– Licensed Practical Nurse (LPN) B removed three vials of [MEDICATION NAME], 20%, 4 ml.
vial, (200 mg. /ml.) from the drawer and placed them on the surface of the medication
cart;
– LPN B opened and dated new nebulizer tubing;
– LPN B opened the three vials and emptied them into the nebulizer chamber;
– He/she said she used three vials because each vial was 200 mg and the order was for 600
mg.;
– He/she attached the nebulizer tubing and put [MEDICAL CONDITION] over [MEDICAL
CONDITION] turned on the machine.
During an interview on 1/25/19, at 1:31 P.M., LPN B said:
– He/she looked at the vial of [MEDICATION NAME] and he/she should have administered 3/4
of the vial;
– He/she looked at the vial and said it was 200 mg./ml, so it should have been 3 ml.
During an interview on 1/28/19, at 11:43 A.M., the Director of Nursing (DON) said:
– If the order is for 600 mg. and it’s a 4 ml. vial, 200 mg./ml., staff should have
administered 3 ml.
3. Review of the facility’s guidance on properly applying [MEDICATION NAME] 5% [MEDICATION
NAME]es, dated, 2/18/16, showed, in part:
– Place the patch to the affected area and apply gentle pressure for approximately 10-15
seconds.
4. Review of Resident #100’s POS, dated, January, 2019, showed:
– an order for [REDACTED].>- an order for [REDACTED].
Review of the resident’s MAR, dated, January, 2019, showed:
– [MEDICATION NAME] 50 mcg., nasal spray, one spray in both nostrils daily for allergies;
– [MEDICATION NAME] 5%, apply to low back topically daily for chronic pain.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
Observation on 1/24/19, at 9:30 A.M., showed:
– CMT A placed the [MEDICATION NAME] topical patch to the inside of the resident’s right
knee;
– CMT A handed the resident the bottle of [MEDICATION NAME] nasal spray and did not give
him/her any instructions;
– The resident sat on the side of the bed and gave him/herself one spray in each nostril;
– The resident did not shake the bottle, have the resident blow his/her nose and did not
close one side of his/her nostril.
During an interview on 1/24/19, at 9:53 A.M., CMT A said:
– The order said to apply to the resident’s lower back and one of the new nurses told
him/her to apply the patch wherever the resident is having pain;
– He/she did not think about shaking the bottle of nasal spray;
– The resident administered it him/herself, he/she just hands the resident the bottle of
nasal spray;
– He/she normally did not have the residents blow their nose beforehand;
– Most of the residents do not hold one side of their nostrils.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
– Staff should follow the physician’s orders [REDACTED].>- If the order says to apply
to the [MEDICATION NAME] to the lower back, it should be applied to the lower back or it
should be clarified;
– Staff should follow the guidelines for the [MEDICATION NAME] nasal spray (shake the
bottle, blow their nose, and close one side of their nostril).
5. Review of the facility’s medication administered by enteral tube, revised, 11/23/18,
showed, in part:
– Certain medications are not intended to be crushed and should not be for administration
via a gastrostomy (G- tube) tube;
– Contact the pharmacy for medications in liquid form and/or alternatives.
Review of the website, www.drugs.com. for [MEDICATION NAME], showed:
– Do not divide, crush or chew.
Review of the website, www.mayoclinic.org. for [MEDICATION NAME], showed:
– Swallow the capsule whole, do not split, crush or chew.
6. Review of Resident #72’s POS, dated, January, 2019, showed:
– an order for [REDACTED].>- an order for [REDACTED].
Review of the resident’s MAR, dated, January, 2019, showed:
– [MEDICATION NAME] 10 mg., one tablet via [DEVICE] three times daily for high blood
pressure;
– [MEDICATION NAME] 25 mg., one tablet via [DEVICE] twice daily for high blood pressure.
Observation on 1/25/19, at 7:45 A.M., showed:
– LPN B placed the [MEDICATION NAME] tablet in a plastic pouch and crushed it and place it
in a plastic medication cup;
– LPN B placed the [MEDICATION NAME] tablet in a plastic pouch and crushed it and placed
it in a plastic medication cup;
– LPN B mixed each medication with 10 ml. of water and administered via the resident’s
[DEVICE].
During an interview on 1/25/19, at 1:31 P.M., LPN B said:
– He/she thought the [MEDICATION NAME] could be crushed unless it’s [MEDICATION NAME]
coated;
– He/she thought the [MEDICATION NAME] could be crushed.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
– [MEDICATION NAME] should not be crushed;
– [MEDICATION NAME] should not be crushed.
7. Review of the facility’s undated drug administration recommendations regarding meals,
showed, in part:
– Humalog insulin- meal should be given within 15 minutes before or immediately after the
meal.
8. Review of Resident #3’s POS, dated, January, 2019, showed:
– an order for [REDACTED].
Review of the resident’s MAR, dated, January, 2019, showed:
– Humalog insulin, eight units subcutaneously before meals for diabetes mellitus.
Observation on 1/24/19, at 11:23 A.M., showed:
– LPN A administered eight units of Humalog insulin and did not offer the resident a
snack.
Observation on 1/24/19, at 12:05 P.M., showed:
– The resident sat at the dining room table and did not have a meal.
Observation on 1/24/19, at 12:13 P.M., showed:
– Staff served the resident a glass of juice;
– The resident did not have a meal.
Observation on 1/24/19, at 12:18 P.M., showed:
– Staff served the resident his lunch and the resident started to eat.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
– If a resident had fast acting insulin the resident should eat within 10-15 minutes or
provide a snack.

F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that residents are free from significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure that
one out of 26 sampled residents, (Resident # 72) were free from significant medication
errors. The facility census was 102.
1. Review of the facility’s medication administration policy, revised 12/14/17, showed, in
part:
– The purpose of this policy is to provide guidelines for general medication
administration to be provided by personnel recognized as legally able to administer;
– Observe the five rights in giving each medication: the right resident, the right time,
the right medicine, the right dose, and the right route;
– Read medication label three times before administering medication, first, when comparing
label to Medication Administration Record [REDACTED].
2. Review of Resident #72’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/5/18, showed:
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED].
Observation and interview on 1/25/19, at 8:46 A.M., showed:
– Licensed Practical Nurse (LPN) B removed three vials of [MEDICATION NAME], 20%, 4 ml.
vial, (200 mg. /ml.) from the drawer and placed them on the surface of the medication

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
cart;
– LPN B opened and dated new nebulizer tubing;
– LPN B opened the three vials and emptied them into the nebulizer chamber;
– He/she said she used three vials because each vial was 200 mg and the order was for 600
mg.;
– He/she attached the nebulizer tubing and put [MEDICAL CONDITION] over [MEDICAL
CONDITION] turned on the machine.
During an interview on 1/25/19, at 1:31 P.M., LPN B said:
– He/she looked at the vial of [MEDICATION NAME] and he/she should have administered 3/4
of the vial;
– He/she looked at the vial and said it was 200 mg./ml, so it should have been 3 ml.
During an interview on 1/28/19, at 11:43 A.M., the Director of Nursing (DON) said:
– If the order is for 600 mg. and it’s a 4 ml. vial, 200 mg./ml., staff should have
administered 3 ml.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interview, ad record review, the facility failed to ensure staff
properly stored and discarded resident medications and stock medications. Staff failed to
date medications when opened and failed to discard expired medications. This had the
potential to affect all residents in the facility. The facility census was 102.
1. Review of the facility’s storage and expiration of medications, biologicals, syringes
and needles policy, revised, 10/31/16, showed, in part:
– Facility should ensure that medications and biologicals that have an expired date on the
label, have been retained longer than recommended by manufacturer or supplier guidelines,
have been contaminated or deteriorated, are stored separate from other medications until
destroyed or returned to the pharmacy or supplier;
– Once any medication biological package is opened, the facility should follow
manufacturer/supplier guidelines with respect to expiration dates for opened medications;
– Facility staff should record the date opened on the he medication container when the
medication has a shortened expiration date once opened;
– Facility should destroy and reorder medications and biologicals with soiled, illegible,
worn, makeshift, incomplete, damaged or missing labels or cautionary instructions;
– Facility should destroy or return all discontinued, outdated/expired, or deteriorated
medications or biologicals;
– Facility should request that pharmacy perform a routine nursing unit inspection for each
nursing station in the facility to assist facility in complying with its obligations.
2. Observation and interview on 1/28/19, at 9:19 A.M., of the medication room for the 400
and 600 halls showed:
– One unopened bottle of Vitamin E (supplement), expired, 8/18;
– One opened bottle of [MEDICATION NAME] Q ([MEDICATION NAME]);
– One unopened bottle of Nephro-Aid, dietary supplement, expired 9/2018;
– One opened vial of [MEDICATION NAME] insulin, no date when opened, the vial stated
filled 8/8/18 and the brown bottle it was kept in had a label that stated filled 9/14/18;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 40)
– One opened vial of [MEDICATION NAME] insulin, no date when opened, the vial stated
filled 7/22/18, the brown bottle with label said 7/22/18;
– An opened vial of Humalog insulin, no date when opened, the vial and brown bottle stated
filled 9/4/18;
– Certified Medication Technician (CMT) A did not know anything about the insulin because
he/she doesn’t do anything with insulin. When we get the medications from the supply room,
we check for expiration dates. Does not know who is responsible to check the medication
room for dates. He/she checks his/her medication cart once a month;
– Opened the bottom cabinet door and both shelves are full of medications (cards &
bottles) which are either expired or the res is no longer in the facility.
Observation on 01/28/19 09:48 AM of the Medication Room for the 100, 200, and 300 halls,
showed:
– One unopened bottle of iron tablets, expired 12/18;
– One bottle of magnesium [MEDICATION NAME], opened, expired 6/13;
– One opened tube of altalube ointment for eyes, expired 12/18;
– Opened cabinet door and two shelves are filled with expired medications or medications
from residents who are no longer in the facility;
– One opened bottle of Vitamin D, expired 10/18;
– One unopened bottle of Vitamin D, expired 10/18;
– One opened bottle of mucous relief, expired 11/18;
– One opened container of prosource , expired (MONTH) 25, (YEAR);
– Opened bottle of [MEDICATION NAME] opth sol. 0.3%, did not have a date when it was
opened;
– Med refrigerator- had two unopened containers of prune juice, 4 fl oz, expired 4/27/18;
– [MEDICATION NAME] 250 mg/ 5 ml, expired 12/15/18.
Observation on 01/28/19 at 10:40 A.M. of the medication room for the 100, 200, and 300
halls, showed:
– [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] sulfate 3 mg- Eight packages with five
vials in a package, expired 10/18, one opened package with three vials left in the
package, expired 10/18, and one unopened package, expired 8/18;
– Medication refrigerator- had an opened vial of [MEDICATION NAME] 2 mg/ml, expired
10/7/18, no date when opened;
– A box of stock [MEDICATION NAME] oral concentrate, unknown staff wrote a resident’s name
on it and on the bottle unknown staff wrote a different resident’s name on it , no date
when it was opened, filled 8/20/18;
– A box of [MEDICATION NAME] suppositories, 25 mg, expired 6/2018;
– An opened vial of [MEDICATION NAME], purified protein derivative, (TB) with no date when
it was opened;
– An opened container of [MEDICATION NAME] concentrate 2 mg/ml, no date when it was
opened, filled 8/10/18;
– In bottom cabinet: one opened tool box used an IV E-kit, expired 3/18, had several 1000
ml., of various types of IV fluids which were expired.
Observation on 01/28/19 at 11:15 A.M. of the 700 skilled unit medication room, showed:
– One opened vial of TB, which did not have a date when it was opened;
– An opened box of [MEDICATION NAME] suppositories, 10 mg, 8 expired 10/2018.
During an interview on 1/28/19, at 11:43 A.M., the Director of Nursing (DON) said:
– Medications should be dated when opened;
– Staff should not tape medications back in the package;
– Staff should not use expired medications;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
– The TB should be dated when it was opened.
During an interview on 1/28/19, at 12:49 P.M., the Assistant Director of Nursing (ADON)
said:
– The pharmacist consultant checks the medication rooms and the medication carts for
expired medications;
– She destroys the expired medications with another CMT and if it’s a narcotic, destroys
it with a nurse;
– She has not destroyed any medications in the last five weeks;
– She was not aware of an IV E-kit that was opened and expired 3/2018.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed protocols to prevent the spread of infection related to hand hygiene during
residents’ personal and wound care This affected four out of 26 sampled residents
(Residents #43, #75, #70, #102). Additionally, staff failed to clean the port of the
insulin pens and failed to properly clean the glucometer between use, which affected,
Resident’s #3 and #37, and failed to clean the port of the drainage bag and use a barrier
when emptying the drainage bag for Resident #103. Staff did not clean a soiled mattress
before applying clean linens for Resident #78. The facility census was 102.
1. Review of the facility’s policy related to standard precautions, revised 4/1/17,
showed:
-The facility will adhere to the CDC (Centers for Disease Control and Prevention)
guidelines and recommendations for hand hygiene unless otherwise explicitly stated.
-[MEDICATION NAME] hand hygiene is a simple but effective way to prevent the spread of
infections, by breaking the chain of infection.
-When hands are not visibly soiled, alcohol-based hand sanitizers are the preferred method
for cleaning hands in this healthcare setting.
-Use soap and water for cleaning hands when hands are visibly dirty or soiled.
-Perform hand hygiene when hands move from a contaminated body site to a clean body site
during patient care, before and after contact with a resident’s intact skin, and after
contact with body fluids or excretions, non-intact skin or wound dressings, and after
glove removal.
2. Review of Resident #43’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/5/18, showed:
-Required extensive assistance for bed mobility and personal hygiene;
-Presence of a urinary catheter (sterile tube inserted into the bladder to drain urine);
-Had a stage 4 (full thickness skin loss) pressure ulcer.
Review of the resident’s care plan, last revised 1/13/19, showed:
-Received wound care for a pressure ulcer to the sacrum (area below the spinal column and
between the hip bones);
-Had a urinary catheter with a recent urinary tract infection [MEDICAL CONDITION];
-Required extensive assistance for personal hygiene and two staff to turn or re-position
him/her.
Observation and interview on 1/24/19 at 9:22 A.M. showed Licensed Practical Nurse (LPN) C
provided wound care in the following manner, and said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 42)
-Gathered wound care supplies on a Styrofoam tray and placed them on a clean field near
the resident’s bedside;
-Washed his/her hands and put on gloves;
-Removed the dressing from the resident’s sacrum, then with the same gloves on, removed a
dressing from the resident’s nephrostomy tube (tube inserted through the skin into the
kidney to drain urine) site, located on the resident’s left side;
-Removed his/her gloves, washed hands and put on clean gloves;
-Cleansed and provided wound care to the sacral wound;
-Removed gloves, washed hands, put on clean gloves;
-Cleansed the nephrostomy tube site and applied a new dressing;
-Removed gloves and washed hands;
-Said the resident received antibiotics for a recent UTI.
During an interview on 1/25/19 at 8:42 A.M., LPN C said:
-Staff should change gloves and wash/sanitize hands after dirty care.
-If wound care sites were unrelated, then staff should remove their gloves and
wash/sanitize their hands.
-Staff should change gloves and wash/sanitize their hands between dressing changes between
a sacral wound and a nephrostomy tube dressing change.
3. Review of Resident #75’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Dependent on staff for activities of daily living;
– Stage IV ( a full thickness skin loss with extensive destruction, tissue death or damage
to muscle tissue) pressure ulcer.
Observation on 1/24/19 at 10:17 A.M., showed:
– Without changing gloves or washing hands between separate areas of wounds, Licensed
practical Nurse (LPN) C, used normal saline and 4X4s to clean the tunneled wound and the
excoriated buttocks and coccyx;
– Without changing gloves or washing hands, LPN C took a piece of [MEDICATION NAME]
(dressing used to treat draining wounds) and with the soiled gloved finger pushed the
[MEDICATION NAME] into the tunneled wound, and used a Qtip to place triple antibiotic
ointment on the buttocks and coccyx area;
– Without changing gloves or washing hands, LPN C covered the areas with dressings.
During an interview on 1/25/19 at 8:50 A.M., LPN C said during dressing changes, he/she
should change gloves and wash hands after you removed the old dressings and if the
resident needed to go to the bathroom, after you assisted them to the bathroom.
4. During an interview on 1/28/19 at 11:45 A.M., the Director of Nurses (DON) said:
– Staff should change their gloves after removing soiled dressings:
– Staff should wash their hands after cleaning each wound;
– Staff should wash their hands between treatments to different areas if the resident had
more than one wound;
– Staff should not use a gloved finger to apply treatment to a wound bed.
5. Review of Resident #70’s annual MDS, dated [DATE], showed:
-Required limited assistance with personal hygiene;
-Always incontinent of bladder.
Review of the resident’s care plan, revised on 1/18/19, showed:
-Incontinent of bladder;
-Check every two hours, and as needed for incontinency;
-Wash, rinse and dry perineum.
During an observation on 1/24/19 at 4:37 P.M., Certified Nurse Aide (CNA) A and CNA H
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 43)
provided care for the resident in the following manner:
-Both staff washed hands and put on gloves;
-Used a sit-to-stand lift to assist the resident to a standing position;
-CNA A cleansed the residents buttocks and rectal areas;
-With the same gloves on, CNA A cleansed the resident’s front genital areas, then removed
his/her gloves and washed hands.
During an interview on 1/24/19 at 4:55 P.M., CNA A said staff should remove their gloves
and wash/sanitize their hands after dirty care, such as cleansing a resident’s backside,
before they cleanse a resident’s front genital areas.
6. During an interview on 1/28/19 at 11:45 A.M., the director of nurses (DON) said:
-Staff should wash/sanitize their hands when entering a resident room and before leaving,
and after glove changes.
-Staff should remove their gloves and wash/sanitize their hands after they remove a sacral
dressing and after they clean fecal material.
-The facility followed the CDC hand hygiene guidelines.
7. Review of Resident #102’s quarterly MDS, dated , 12/11/18, showed:
– Cognitive skills intact;
– Lower extremities impaired on both sides;
– Had a Foley catheter (sterile tube inserted into the bladder to drain urine);
– [DIAGNOSES REDACTED].
Review of the resident’s undated care plan, showed:
– The resident had an indwelling catheter;
– Position the catheter bag and tubing below the level of the bladder;
– Monitor and document intake and output.
Observation on 1/25/19, at 11:20 A.M., showed:
– CNA B placed the urinal directly on the floor without a barrier;
– CNA B opened the spout and emptied 150 ml., of dark yellow urine in the urinal;
– CNA B did not clean the port and replaced it in the sleeve.
During an interview on 1/25/19, at 1:46 P.M., CNA B said:
– He/she should have placed the urinal on a clean barrier;
– He/she was not for sure if the port should have been cleaned.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
– Staff should clean the spout with an alcohol wipe;
– Staff should have a barrier for the urinal to set on.
8. Review of the facility’s cleaning and disinfection of glucose meter policy, revised
10/8/18, showed, in part:
– This facility uses shared devices for glucose testing and will perform cleaning and
disinfection procedures between each resident;
– Use an EPA approved disinfectant to thoroughly wet all surfaces for the time
recommendation on the product;
– Place a clean barrier on resident bedside table, over bed table or other hard surface
area when testing;
– Do not place the glucometer directly on the bed or chair;
– Return glucometer after use for disinfection process placing on a clean barrier until
disinfection/cleaning is completed;
– Do not place a contaminated glucometer top of the medication cart or other surface
without a clean protective barrier;
– Disinfect the glucometer immediately before re-use with an EPA approved wipe;
– Alcohol wipes are not appropriate for cleaning/disinfection a used glucometer.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 44)
9. Review of Resident #3’s care plan, revised, 10/4/18, showed:
– The resident had diabetes mellitus;
– Diabetic medication as ordered.
Review of the resident’s POS, dated, January, 2019, showed:
– an order for [REDACTED].
Observation and interview on 1/24/19, at 11:23 A.M., showed:
– LPN A removed the glucometer from the medication cart and placed it on a Kleenex on the
surface of the cart;
– LPN A said he/she had already cleaned the glucometer;
– LPN A did not clean the port of the insulin pen and attached the needle;
– LPN A used the glucometer and obtained the resident’s blood sugar and administered the
insulin;
– LPN A placed the glucometer on a Kleenex on the medication cart;
– LPN A used an alcohol wipe and cleaned the glucometer then placed it back in the top
drawer of the medication cart.
10. Review of Resident #37’s care plan, revised, 2/14/18, showed:
– The resident had diabetes mellitus;
– Diabetes medication as ordered.
Review of the resident’s POS, dated, January, 2019, showed:
– an order for [REDACTED].
Observation on 1/24/19, at 11:41 A.M., showed:
– LPN A placed the second glucometer on a Kleenex on the surface of the medication cart;
– LPN A did not clean the port on the insulin pen and attached the needle;
– LPN A used the glucometer and obtained the resident’s blood sugar and administered the
insulin;
– LPN A placed the glucometer on a Kleenex on the medication cart;
– LPN A used an alcohol wipe and cleaned the glucometer then placed it back in the top
drawer of the medication cart.
During a telephone interview on 1/31/19, at 1:12 P.M., LPN A said:
– He/she should let the fingertip air dry before he/she obtained the resident’s blood
sugar;
– He/she should have cleaned the port of the insulin pen before attaching the needle;
– He/she should have cleaned the glucometer with a sani wipe instead of an alcohol wipe.
During an interview on 1/28/19, at 11:43 A.M., the DON said:
– Staff should clean the glucometer with a bleach sani wipe;
– The port of the insulin pen should be cleaned with an alcohol wipe.
11. Review of Resident #78’s MDS, dated [DATE]. showed:
– Unable to determine resident’s ability to make daily decisions, (the resident spoke
another language);
– Required assistance with activities of daily living;
– Always incontinent of bowel and bladder.
Observation and interview on 1/26/19 at :01 P.M., showed CNA G did a complete bed change
due to Resident #79 being incontinent. When CNA G turned the resident to his/her side and
rolled the wet bed linens under the resident, the mattress was wet. CNA G wiped an area of
the mattress about five inched wide and 18 inches long with a pre-moistened wipe and
transferred the resident into his/her wheelchair. CNA G removed the soiled bed linen. This
revealed a tear in the top layer of there resident’s mattress. The torn top of the
mattress was wrinkled and exposed the underneath part of the mattress about two feet in
length and ten inches in width, CNA G did not clean any more of the mattress before he/she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265697

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/29/2019

NAME OF PROVIDER OF SUPPLIER

GARDEN VALLEY HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

8575 NORTH GRANBY AVE
KANSAS CITY, MO 64154

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 45)
put the bed linens on the mattress. CNA G said he/she did not know when the mattress got
deep cleaned or when the resident would get a new mattress. He/she would tell the charge
nurse about the mattress.
During an interview on 1/28/19 at 11:45 A.M., the Director of Nurses (DON) said:
– Staff could have used sanitation wiped to clean the mattress, a wipe used to clean the
resident would not sanitize the mattress;
– She thought housekeeping staff cleaned the mattresses on the resident’s shower days and
during the once a month deep clean day of the resident’s room;
– The resident should not be on a mattress that was ripped, he/she would let maintenance
know about the mattress.