Garden Valley Retirement Village

Inspectors wroteThe facility reported a census of 45, which included four residents that had physician orders for pureed diets. Based on observation, interview, and record review the facility failed to provide food prepared in accordance with recipes to ensure conservation of nutritive value, flavor, palatability, and appearance for four residents that received pureed diets. This placed the affected residents at risk for impaired nutrition and diminished enjoyment of their meals.

Inspectors wroteThe facility reported a census of 45 residents. The sample included 12 residents, with two residents reviewed for discharge. Based on observation, interview, and record review the facility failed to ensure that the discharge needs were identified, and an appropriate discharge plan was created for Resident (R) 39. This placed the resident at risk for unmet care needs and inappropriate discharge.

Inspectors wroteThe facility reported a census of 45 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 43 received services to maintain his abilities of activities of daily living (ADL). This deficient practice placed the resident at risk for a decrease in functional abilities and decreased independence.

Inspectors wroteThe facility reported a census of 45 residents. The sample included 12 residents with one dependent resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide ADL care including grooming of facial hair for Resident (R) 45. This placed the resident at risk for impaired dignity and poor hygiene.

Inspectors wroteThe facility reported a census of 45 residents, with 12 residents sampled. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when the facility failed to identify and change ineffective fall interventions and failed to fully implement all interventions aimed at preventing falls for Resident (R) 38, who had multiple falls. This deficient practice placed R38 at risk for further falls and related injuries.

Inspectors wroteThe facility reported a census of 45 residents, with 12 residents sampled. Based on observation, interview, and record review, the facility failed to provide adequate care and services for Resident (R) 41's peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) when staff failed to perform the PICC dressing change every five days and failed to label the antibiotic medication that was administered. These deficient practices placed R41 at risk for complications related to the PICC line and medication administration via the PICC.

Inspectors wroteThe facility reported a census of 45 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to implement provider orders based on the Consultant Pharmacist's (CP) monthly medication review (MRR) and ensure an MRR review system that mitigated duplication or omissions for Resident (R) 38. The deficient practice placed the resident at risk of receiving unnecessary medications.

Inspectors wroteThe facility reported a census of 53 residents with 13 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for one Resident (R)41, with failure to identify poor dentition (of, or related to teeth) as evidenced by worn and broken teeth. This placed the resident at risk for uncommunicated care needs.

Inspectors wroteThe facility reported a census of 53 residents with 13 residents reviewed. Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for Resident (R)41 for the provision of needed dental services and R7 for care and maintenance of an indwelling urinary catheter (a hollow flexible tube that collects urine and leads to a drainage bag). This placed the residents at risk to not receive appropriate cares and treatments.

Inspectors wroteThe facility census totaled 53 residents with 13 residents included in the sample. Based on observation, interview, and record review the facility failed to revise Resident (R) 8's care plan related to physician ordered stockings used for edema.

Inspectors wroteThe facility census totaled 53 residents, with 13 sampled, including five residents for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of black box warnings (BBW- serious or life-threatening side effects of medications) for two of the five residents reviewed. Resident (R) 13 and R29. These failures placed the residents at risk for adverse effects related to monitoring of BBW medication use. Findings Included: [...]

Inspectors wroteThe facility census totaled 53 residents, with 13 sampled, including five residents for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure adequate monitoring of black box warnings (BBW- serious or life-threatening side effects of medications) for psychotropic (affects how the brain works and causes changes in awareness, thoughts, feelings, or behaviors) medications for three of the five residents reviewed. Resident (R) 13, R17, and R28. These failures placed the residents at risk for adverse effects related to monitoring of BBW psychotropic medication use. Findings Included: [...]

Inspectors wroteThe facility reported a census of 53 residents, with 13 residents sampled, including one resident reviewed for dental services. Based on interview and record review, the facility failed to provide dental services or access to dental services for Resident (R) 41, due to widespread dental decay. This placed the resident at risk for further deterioration of dentition (of or having to do with teeth).

Inspectors wroteThe facility reported a census of 50 with 16 sampled residents. Based on interview and record review the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized in accordance with accepted professional standards and practices by the failure to have resident information scanned into the Electronic Health Record (EHR) in a timely manner.

Inspectors wroteThe facility census totaled 50 with 16 residents sampled. Based on observation, interview, and record review the facility failed to provide Resident (R) 42 with the right to a dignified existence when staff failed to serve her in a timely manner once she was seated for the noon meal on 08/16/21. R42 waited nearly an hour for her meal at the table, while other residents around her ate and staff served another resident who arrived to the table after R42.

Inspectors wroteThe facility had a census of 50 residents with 16 included in the sample. Based on interview and record review the facility failed to provide Resident (R) 28, R42, and R150 or their representative with a bed-hold policy upon transfer to a hospital.

Inspectors wroteThe facility reported a census of 50 residents, with 16 sampled, including one for accuracy of assessments in the Minimum Data Set (MDS). Based on observation, interview, and record review the facility failed to accurately document resident (R) 35's dental status by the failure to document the broken dentures of R35.

Inspectors wroteThe facility reported a census of 50 residents, with 16 residents sampled, including one for review of dental services. Based on observation, interview, and record review the facility failed to provide Resident (R) 35 with the assistance needed to repair her broken dentures after staff identified it as a concern over two months prior, 06/17/21-08/19/21.

Inspectors wroteThe facility census totaled 50 with 16 residents sampled. Based on observation, interview, and record review the facility failed to provide Resident (R) 46 with adaptive eating utensils and/or plate to improve the residents' ability to eat independently.