Inspection Reports for
Diversicare of Chanute

The facility completed investigations on residents R1 and R2, with R1 expired on 3/31/26. The facility has implemented education and monitoring plans to ensure timely reporting and compliance with abuse/neglect/exploitation policies.

Complaint investigation involved three complaint reference numbers. The allegation of resident-to-resident abuse was substantiated as the facility failed to report and investigate the incident properly.

The facility failed to ensure staff immediately reported an incident of resident-to-resident abuse allegation to the Administrator and to the State Agency. The incident involved a resident pinching another resident, which was not reported timely or fully investigated according to policy.

The facility addressed deficiencies related to hospice care, including ensuring residents received their personalized physician-ordered medication regimens and assessing hospice residents for signs of terminal agitation and anxiety.

The survey was triggered by allegations in complaint number 2792062.

The facility failed to ensure Resident 1 received necessary care including his personalized physician-ordered medication regimen, resulting in increased anxiety/agitation, a fall with injury, and low back pain. The report details medication management issues, including inappropriate discontinuation of psychotropic medications and resulting resident distress.

The plan outlines corrective actions for deficiencies related to psychotropic informed consent, environmental repairs and cleaning, nail care provision, and nursing staffing information posting. The facility commits to audits and education to ensure compliance by October 23, 2025.

The facility was found deficient in ensuring informed consent for psychotropic medications, maintaining a safe and homelike environment, providing adequate personal care such as nail care, and posting accurate nurse staffing information daily.

The survey included complaint investigations related to allegations in cases 2619946, 575460, and 2578024.

The facility failed to ensure residents' rights to be informed and make treatment decisions, maintain a safe, clean, and homelike environment, provide adequate care for dependent residents, and post accurate nurse staffing information. Multiple deficiencies were identified related to medication consent, environmental conditions, resident care, and staffing data.

The facility identified issues related to Saturday mail delivery and meal delivery temperatures, including proper logging of substitutions. Corrective actions and audits have been planned to ensure compliance and ongoing monitoring.

The facility failed to provide residents reasonable access to receive mail on Saturdays and failed to provide food that was nutritionally balanced, palatable, attractive, and served at safe and appetizing temperatures. These deficiencies placed residents at risk for inadequate nutrition and decreased quality of life.

The complaint investigation was triggered by concerns that residents did not receive mail on Saturdays and complaints about food quality, temperature, and lack of alternatives. The complaints were substantiated by observations, interviews, and record reviews.

The facility failed to provide residents reasonable access to receive mail on Saturdays and failed to provide food that was nutritionally balanced, palatable, attractive, and served at safe and appetizing temperatures, placing residents at risk for inadequate nutrition and decreased quality of life.

The investigation was complaint-driven based on concerns about wound care, infection control, medication management, and pest control. Maggots were found on Resident 1's leg during a wound clinic appointment, and flies were observed in his room. The facility failed to follow physician orders for wound care and failed to monitor and treat constipation for another resident.

The facility failed to ensure proper wound care for Resident 1, resulting in maggots found on his leg dressings. The facility also failed to follow physician orders for wound treatment for Resident 4, did not monitor and treat constipation for Resident 3, and failed to maintain effective infection prevention and pest control programs.

Complaint investigation #KS00188676 focused on quality of care issues including wound care, infection control, medication management, and pest control.

The facility failed to ensure Resident 1 had clean and dry dressings, resulting in maggots found on his leg. The facility also failed to follow physician orders for wound care for Resident 4, failed to monitor and treat constipation for Resident 3, failed to maintain infection control practices during dressing changes, and failed to maintain an effective pest control program as evidenced by flies and maggots in Resident 1's room.

The facility addressed deficiencies related to wound care, physician order compliance, bowel movement documentation, infection control, and pest control. The Plan of Correction outlines education, audits, and monitoring activities to ensure compliance and quality improvement.

The facility addressed multiple deficiencies including environmental repairs, care plan updates for falls and blood pressure management, restorative therapy assessments, accident hazard prevention, dialysis documentation, nurse aide evaluations, pharmacy procedures, drug regimen monitoring, food sanitation, and payroll-based journal accuracy. Staff education and ongoing audits are planned to ensure sustained compliance.

The complaint investigation #KS00186602 focused on respiratory care and medication administration issues involving Residents R1 and R5.

The facility failed to administer physician-ordered oxygen correctly for two residents, including failure to maintain oxygen supply and proper flow rates. Additionally, the facility failed to start a prescribed anticoagulant medication for 22 days after the order, and did not notify the cardiologist about the fistula placement appointment for medication management.

The facility failed to provide oxygen as ordered for two residents, resulting in inadequate respiratory care. Additionally, the facility failed to start a physician-ordered anticoagulant medication for one resident, causing a 22-day delay in administration.

The facility addressed deficiencies related to respiratory/tracheostomy care and pharmacy services, including oxygen settings and initiation of physician orders. Staff education and ongoing audits are planned to ensure compliance.

Complaint Investigation #185790 was part of the visit.

The facility failed to maintain a safe, sanitary, and homelike environment, failed to review and revise care plans for residents after falls and medication changes, failed to provide restorative services, failed to initiate appropriate fall interventions, failed to assess residents post dialysis, failed to complete annual performance reviews for staff, failed to follow physician orders for medication administration and notification, failed to maintain food safety standards, and failed to accurately submit payroll based journal staffing data.

The facility failed to maintain a safe, sanitary, and homelike environment, failed to revise care plans appropriately following falls and medication parameters, failed to provide restorative services, failed to ensure proper dialysis post-assessment, failed to complete annual staff performance reviews, failed to follow physician orders for medication administration, failed to maintain proper food safety standards, and failed to accurately report staffing data to CMS.

The complaint investigation substantiated that CNA M failed to secure the resident with a lap/shoulder belt during transport, resulting in the resident falling and sustaining injuries. Immediate jeopardy was identified on 12/14/23 and corrective actions including suspension of CNA M and staff education were implemented the same day.

The facility failed to ensure a safe environment by not securing the resident with a lap/shoulder belt during transport, resulting in the resident falling out of the wheelchair and sustaining multiple injuries including a left distal radius fracture, right flank hematoma, and acute blood loss anemia. Immediate jeopardy was identified and corrective actions were implemented on the day of the incident.

The facility was found deficient in multiple areas including quality of care, pressure ulcer treatment, accident prevention, catheter care, dialysis follow-up, nursing staffing, pharmacy services, medication administration, food quality, therapeutic diet provision, food safety, infection control, COVID-19 immunization education, and equipment maintenance.

The facility failed to provide sanitary dressing changes, appropriate pressure ulcer care, fall prevention interventions, proper catheter care, follow-up on dialysis communications, adequate nursing staffing, timely medication administration, palatable food, therapeutic renal diet, sanitary food storage and preparation, effective infection control practices, and timely COVID-19 vaccine education and documentation.

The facility addressed deficiencies related to staff qualifications for medication administration. Education was provided to nursing staff, and monitoring and audits were planned to ensure ongoing compliance.

The visit was triggered by complaint investigations #157758, #167477, and #167533. The complaint was substantiated as the facility allowed an uncertified CNA to administer medications.

The facility failed to ensure that only qualified certified medication staff administered medications to residents on the west unit. A Certified Nurse Aide (CNA M) without Certified Medication Aide (CMA) certification administered medications to 20 residents on Thanksgiving Day, November 25, 2021, under the supervision of a Licensed Nurse (LN G).

The facility addressed deficiencies involving timely reporting and investigation of alleged violations of abuse/neglect/misappropriation policies and improper storage of medications. Corrective actions include staff reeducation, policy reviews, audits, and securing medications in locked cabinets.

The complaint investigation #KS 00162982 involved allegations of drug diversion (theft) of narcotic medications by a licensed nurse. The allegation was not reported timely to the State Agency and was not thoroughly investigated. The investigation lacked proper documentation and witness statements. The facility also failed to secure medications properly.

The facility failed to report the allegation of drug diversion to the State Agency and did not thoroughly investigate the allegation. Additionally, the facility failed to ensure safe and secure storage of controlled medications, as the medication lock box was structurally compromised and allowed potential unauthorized access.

The inspection included complaint investigations #154623, #153170, and #150316.

The facility was found deficient in multiple areas including failure to provide written bed-hold notice upon resident transfer, inaccurate resident assessments, failure to develop individualized care plans, inadequate restorative services, failure to provide appropriate oral care, failure to prevent and treat pressure ulcers, failure to maintain respiratory equipment properly, failure to provide individualized nurse aide in-service training, failure to act on pharmacy recommendations, and failure to administer medications appropriately.

The plan addresses multiple deficiencies including bed hold policy compliance, MDS accuracy, care plan updates, oral hygiene, wound care, restorative therapy, oxygen equipment maintenance, nurse aide evaluations, pharmacy recommendations, medication administration, and QAPI meeting effectiveness.

The plan addresses infection control deficiencies including staff screening, education on infection control practices, and ongoing audits to ensure compliance with COVID-19 protocols.

The facility failed to perform appropriate staff screening including temperature checks on 42 occasions and allowed staff with temperatures of 100.0°F or greater to work on four occasions, placing residents at immediate jeopardy. The facility implemented a plan of correction and the immediate jeopardy was removed, but the deficiency remained at severity level F.

This report is based on complaint investigation #147644. The complaint was substantiated as the facility failed to reposition a resident as required, leading to pressure ulcer risk.

The facility failed to timely reposition a dependent resident, resulting in pressure ulcer risk due to prolonged time in the same position without assistance. Observations and staff interviews confirmed the resident remained in a wheelchair for over four hours without repositioning.

Residents were found to require repositioning and incontinent care; skin status assessments and documentation were incomplete. Staff education on abuse, neglect, turning, repositioning, and pressure ulcer prevention was conducted, and ongoing audits were planned.

The plan addresses deficiencies related to residents' ADL care needs, restorative range of motion therapy, and staffing schedules. The facility outlines corrective actions including reassessments, education of staff, audits, and ongoing monitoring to achieve substantial compliance by August 28, 2019.

The complaint investigation (#144151) was substantiated with findings of inadequate bathing and restorative care for four residents, and insufficient nursing staff to meet resident needs.

The facility failed to provide adequate bathing assistance and restorative range of motion (ROM) services to four sampled residents, resulting in unmet care needs. Additionally, the facility lacked sufficient nursing staff to provide necessary care and supervision.

The complaint investigation #140700 was substantiated by findings that the facility failed to provide safe transportation, resulting in resident injury.

The facility failed to provide safe transportation for a resident, resulting in the resident falling out of a wheelchair in the van due to the lap and shoulder restraint belt becoming unhooked from the floor track. The resident sustained fractures, lacerations, bruising, and required hospital treatment. The facility lacked proper van maintenance documentation and failed to ensure the floor tracks were free of debris.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, identified as past non-compliance for F689, "G", CFR 483.25(d)(1)(2). Based on this and prior non-compliance, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.

The visit was complaint-related, triggered by allegations of resident mistreatment, neglect, and inadequate care. The investigation found substantiated issues including verbal abuse, neglect in care and supervision, and failure to report and investigate incidents properly.

The facility failed to ensure residents were treated with dignity, provide a safe and clean environment, report alleged violations timely, conduct thorough abuse investigations, complete timely assessments and care plans, provide adequate restorative nursing services, prevent accidents, maintain sufficient staffing, ensure medication administration safety, provide adequate activities, and maintain a safe environment.

The plan outlines corrective actions addressing multiple deficiencies including resident dignity, environmental repairs, abuse/neglect investigations, care plan updates, wound care, medication administration, staffing, and safety equipment. The facility commits to ongoing audits and education to ensure compliance.

The plan addresses multiple deficiencies including failure to provide residents with state survey agency contact information, medication administration issues, incomplete assessments, care plan updates for pressure ulcers and urinary catheters, discharge summaries, activity programming, hospice coordination, infection control, food service sanitation, and antibiotic stewardship. The facility describes education, audits, and monitoring to achieve substantial compliance by May 23, 2018.

The visit included investigation of multiple complaints (#112672, #113634, #116949, #117713, #121609, #122891, #124601) related to resident rights, abuse, neglect, medication errors, and infection control.

The facility had multiple deficiencies including failure to provide required resident notices, failure to report alleged violations, inaccurate resident assessments, failure to revise care plans, inadequate discharge summary, insufficient activity programs, poor quality of care coordination with hospice, ineffective pressure ulcer prevention and treatment, medication regimen review failures, food service temperature and sanitation issues, infection prevention and control failures, and lack of an effective antibiotic stewardship program.

The plan addresses deficiencies related to oral assessments and dental care for residents, including completion of oral assessments, dental appointments for Resident #1, and education of nursing staff on oral care.

The visit was triggered by complaint investigation #121726. The complaint was substantiated as the facility failed to provide adequate dental services and assessments for residents.

The facility failed to ensure one resident received adequate dental assessment and care. The resident's dental issues were not identified or addressed timely, and the facility lacked a system to identify residents needing dental services. Routine oral assessments were not completed as required, and the facility lacked a dental services policy.

The survey found the most serious deficiency to be an 'E' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective October 20, 2017.

The survey found the facility was not in substantial compliance and constituted Immediate Jeopardy and Past Non-compliance to resident health or safety for F155, "L", CFR 483.10(c)(6)(8)(g)(12),483.24(a)(3). Enforcement remedies will be recommended without opportunity for correction before imposition.

This plan of correction is linked to a complaint investigation identified as DVC Chanute complaint 06282017.

The plan addresses past non-compliance issues identified under tags F0000 and F155-L, with no new corrective actions required.

The complaint investigation (#117428) substantiated that the facility failed to honor a resident's full code status by not initiating CPR and failed to maintain accurate code status documentation for multiple residents.

The facility failed to initiate CPR for a resident who was a full code and found unresponsive without vital signs. Additionally, the facility did not maintain accurate and accessible code status documentation for 10 of 69 residents, placing residents at immediate jeopardy.

All previously cited deficiencies were reviewed and corrective actions were completed by 04/25/2017. No uncorrected deficiencies remain as of the revisit date.

The plan addresses a deficiency related to the monitoring and assessment of residents with pacemakers, specifically noting corrective actions taken for Resident #5 and education provided to nursing staff.

The report confirms that the deficiencies previously reported have been corrected as of the indicated correction dates.

The complaint investigation #114606 focused on the facility's failure to provide adequate care and monitoring for residents with pacemakers. The investigation substantiated that the facility did not ensure monitoring of the pacemaker function for one resident.

The facility failed to adequately monitor one resident with a pacemaker by not obtaining or clarifying physician orders for pacemaker checks and lacking a policy for monitoring pacemaker functioning. The resident had not had a pacemaker check since admission, and the facility did not ensure a system to assess the pacemaker's function.

The survey found the most serious deficiency to be a "D" level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

This plan of correction addresses deficiencies cited in response to a complaint investigation (DVC Chanute complaint 03302017).

Resident #1 was assisted back into the center without injury after an elopement incident. The facility implemented new interventions including updated care plans, staff and vendor education, and signage to prevent future elopements.

The survey found the most serious deficiencies to be a 'D' level deficiency, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

The survey found the most serious deficiencies to be a 'D' level deficiency, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

The complaint investigation was triggered by complaint #113696 concerning the elopement of resident #01. The resident exited the facility without staff knowledge due to a vendor holding the door open. The resident was found outside within 15 minutes without injury. The facility updated care plans and trained vendors to prevent recurrence.

The facility failed to provide adequate supervision and assistive devices to prevent a resident from eloping when a vendor staff opened the front door and allowed the resident to exit without staff knowledge. The resident was found and returned without injury.

The revisit confirmed that the previously reported deficiency under regulation 483.10(f)(1)-(3) was corrected by the revisit date of 12/29/2016. No other deficiencies or uncorrected issues were noted.

This plan of correction is related to a complaint investigation identified as DVC Chanute complaint 12222016.

The facility failed to ensure all residents received their preferred breakfast choice, specifically one resident who did not receive shredded wheat as ordered. The dietary team was re-educated and audits were planned to ensure compliance.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 29, 2016.

Complaint investigation #105926 focused on the resident's right to make choices, specifically regarding meal selection. The complaint was substantiated as the facility failed to consistently provide the resident's preferred menu choice.

The facility failed to provide one resident (resident #1) with their menu preference choice for breakfast despite the resident's documented preferences and family concerns. Staff reported issues with availability and preparation of the preferred rice dish, resulting in the resident sometimes receiving alternative cereals instead.

The facility identified multiple deficiencies related to environmental conditions, resident assessments, medication management, infection control, and housekeeping. Corrective actions include staff re-education, audits, repairs, and ongoing monitoring through the Quality Assurance Performance Improvement (QAPI) committee.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection included complaint investigations #102138 and #102770. Specific substantiation status was not stated.

The facility failed to maintain a sanitary environment, provide accurate resident assessments, ensure appropriate medication use and timely pharmacist recommendations, maintain sanitary food storage and preparation, monitor expired medications, and uphold infection control practices.

The report confirms that all previously cited deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h) have been corrected as of April 8, 2016.

The report confirms that all previously identified deficiencies have been corrected as of April 8, 2016, with no outstanding issues remaining at the time of the revisit.

The inspection was triggered by complaints alleging neglect and inadequate investigation/reporting of resident falls resulting in injuries.

The facility failed to thoroughly investigate and report possible neglect related to two residents who fell and sustained fractured hips. The facility also failed to provide appropriate interventions and supervision to prevent repeated falls, lacked a policy for accident/fall investigations, and staff were unaware of the 'Call before you Fall' program.

This Plan of Correction is related to deficiencies cited during a complaint investigation triggered by the DVC Chanute complaint dated 03/25/2016.

The facility identified deficiencies related to resident care plans, fall interventions, and abuse/neglect policies. The Plan of Correction outlines actions to educate staff, reassess care plans, report falls and injuries, and monitor compliance through Quality Assurance meetings.

The report confirms that the previously reported deficiencies have been corrected as of the revisit date.

The investigation was triggered by complaint #97169. The complaint was substantiated as the facility failed to provide the ordered chemotherapy medication in a timely manner.

The facility failed to provide chemotherapy medication as ordered for one skilled care resident, resulting in a 21-day delay in administration of the prescribed drug Xtandi. The delay was due to the facility's inability to timely acquire the medication, which had a significantly increased cost.

The survey found a most serious deficiency at level D, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

This plan of correction is related to a complaint investigation identified as Diversicare of Chanute complaint 02242016.

The facility had a medication administration deficiency involving a resident who received chemotherapy medication on February 17, 2016. An audit was conducted to identify other residents potentially affected by missing medications.

This Plan of Correction is related to a complaint investigation at Diversicare of Chanute dated January 29, 2016.

The plan addresses deficiencies related to elopement risks, including changing door codes, educating staff on notification procedures, reviewing and updating care plans for residents at risk, and ensuring new admissions are educated on elopement protocols.

The complaint investigations #96423, #96590, and #96630 were related to failure to report elopement incidents and inadequate supervision of residents at risk of elopement. The allegations were substantiated based on the findings.

The facility failed to report an elopement of a resident to the state agency as required and failed to provide adequate supervision and assistive devices to prevent the elopement of one resident. The resident left the facility without staff knowledge, traveled approximately 20 miles to their home, and returned without staff awareness until family notification.

The report documents that the previously identified deficiency under regulation 483.25(h) was corrected as of the revisit date. No other deficiencies are noted.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The investigation was triggered by complaint #93721. The complaint was substantiated as the facility failed to prevent a fall for resident #01, who sustained injuries.

The facility failed to provide adequate supervision and a working personal alarm to prevent a resident from falling, resulting in an abrasion and swelling. The resident fell from a wheelchair while unattended by staff, despite having a personal alarm that failed to sound.

The facility identified issues related to the use and monitoring of personal alarms for residents. Corrective actions include staff education, alarm checks, care plan reviews, and ongoing monitoring to ensure compliance.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The report documents that the previously cited deficiency under regulation 483.25(h) was corrected as of the revisit date.

This Plan of Correction addresses deficiencies cited during a complaint investigation survey, specifically related to patient elopement risks and interventions.

The facility updated care plans and implemented interventions to address elopement risks, including new assessments, staff education, door alarm replacements, and elopement drills. Patient #2 was moved to a more secure Alzheimer’s unit to ensure safety.

The report confirms that all previously reported deficiencies have been corrected as of the revisit date.

This was a non-compliance revisit for complaint investigations #89255, 89062, 88518, 87562 and current complaint investigations #91502 and 89938. The resident eloped on 9/7/15 and 9/10/15 despite being identified as at risk and under 15-minute checks. Staff failed to maintain supervision and accurate documentation of checks. The resident had access to the door code and removed the wanderguard bracelet multiple times.

The facility failed to provide adequate supervision to prevent elopement for one resident who left the building without staff knowledge twice within three days. The resident was at risk for wandering and elopement, had a history of removing a wanderguard bracelet, and staff failed to consistently perform required 15-minute checks.

The inspection was triggered by complaint investigations numbered 89255, 89062, 88518, and 87562.

The facility failed to report significant changes in resident conditions, develop temporary care plans, monitor skin issues, provide adequate ADL care, maintain hydration, monitor medications properly, and provide sufficient staffing to meet resident needs.

This Plan of Correction addresses deficiencies cited during a complaint survey at the facility.

The facility submitted corrective actions addressing multiple deficiencies including vital sign monitoring, initial admission care plans, skin issue documentation, hygiene and grooming, hydration, shower completion, and medication delivery processes. Education, monitoring, and reporting measures were implemented to ensure substantial compliance by 09/04/2015.

The report documents that all previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies have been corrected as of the revisit date.

The facility outlined corrective actions to address deficiencies related to care plan updates, personal care procedures, and hydration risk management. The plan includes staff training, audits, and monitoring to ensure compliance and patient-centered care.

The inspection was triggered by complaint investigations #83730 and #83817.

The facility failed to provide one resident their choice of bathing frequency, failed to provide proper incontinence care to prevent urinary tract infections for another resident, and failed to provide adequate assistance for hydration to a resident at risk for dehydration.

The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The revisit confirmed that the previously cited deficiency with regulation 28-39-160 (ID Prefix S0770) was corrected as of 03/11/2015.

The report confirms that the previously identified deficiency with regulation number 28-39-160 (ID Prefix S0770) was corrected as of 03/11/2015.

The facility will no longer provide Daycare Services and has implemented staff education on elopement policies. New elopement assessments were conducted, door alarm key codes changed, and ongoing monitoring of doors established to ensure compliance.

The complaint investigation #84102 found that a cognitively impaired resident exited the facility unnoticed on a cold night and was found lying in a ditch requiring EMS intervention. The facility failed to assess the resident's elopement risk and did not inform the family of the incident promptly.

The facility failed to provide adequate supervision to prevent a cognitively impaired resident from leaving the facility unnoticed, resulting in the resident being found lying in a ditch in cold weather. The facility also lacked a day care policy and failed to complete an assessment for the resident's individualized care needs upon admission to day care.

The survey found the most serious deficiency to be an "E" level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The survey found the most serious deficiency to be an "E" level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The visit was triggered by a complaint investigation (#69055) concerning allegations of abuse and neglect, which were found substantiated due to inadequate investigations and reporting by the facility.

The facility failed to thoroughly investigate and report incidents of alleged abuse and neglect, maintain sanitary and safe conditions, update care plans timely, provide appropriate catheter care, and implement infection control measures. Multiple deficiencies were found related to abuse investigations, housekeeping, care planning, catheter management, resident safety, and infection control.

The plan addresses multiple deficiencies including staff education on dignity and patient rights, individualized care planning, environmental repairs, oral health assessments, therapy evaluations, dietary menu compliance, and sanitation improvements. The facility outlines corrective actions, monitoring, and timelines to achieve substantial compliance by September 28, 2012.

The facility was found deficient in multiple areas including failure to provide resident privacy during care, inadequate activities programming, housekeeping and maintenance deficiencies, incomplete comprehensive assessments, failure to revise care plans for positioning, inadequate positioning devices, failure to follow pureed diet menus, failure to provide timely dental services, and unsanitary kitchen conditions.

The plan indicates that the cited deficiencies F0000 and F689-G were past noncompliance issues for which no plan of correction was required.