Inspection Reports for
Diversicare of Council Grove

The Plan of Correction addresses multiple deficiencies including resident privacy during dressing changes, environmental cleanliness and comfort, wound care quality, infection prevention and control, and pest control program effectiveness. The facility outlines corrective actions, staff education, and ongoing audits to ensure compliance.

The inspection was triggered by multiple complaint investigations (KS00196358, KS00196222, KS00196202, KS00196134, KS00193119, KS00195995) concerning resident rights violations, poor quality of care, infection control lapses, and pest control failures.

The facility was found deficient in treating residents with dignity and privacy, maintaining a clean and homelike environment, providing adequate wound care resulting in maggot infestation, maintaining effective infection prevention and control practices, and ensuring effective pest control to manage a fly infestation.

The facility was found deficient in multiple areas including failure to provide dignified care with privacy, inadequate wound care leading to maggot infestation, poor environmental cleanliness with persistent urine odor, ineffective infection control practices including poor hand hygiene, and insufficient pest control measures resulting in a fly infestation.

The center rescinded a discharge notice for a resident and provided education to leadership on clinical documentation requirements. The Administrator will review clinical documentation for all involuntary discharges during daily meetings to ensure compliance.

The investigation involved multiple complaint investigations regarding an involuntary discharge of Resident 1. The discharge was found to be inappropriate due to lack of documentation and failure to meet regulatory requirements. The resident's behavioral issues were documented but interventions and incident reports were insufficient or missing. The facility did not report a resident-to-resident threat and lacked a discharge policy.

The facility initiated a 30-day involuntary discharge for Resident 1 without documented evidence validating the reason for discharge. The resident exhibited behavioral issues directed primarily at staff, but the facility lacked documentation that the resident's needs could not be met or that other residents were endangered. The facility also failed to report a resident-to-resident threat as required and did not have a policy related to involuntary discharge.

The complaint involved an involuntary discharge of Resident R1. The discharge was not substantiated by clinical evidence or documented behavioral interventions. The facility lacked incident reports for alleged inappropriate behaviors and did not have a policy on involuntary discharge. The Long-Term Care Ombudsman requested withdrawal of the discharge letter due to changed circumstances.

The facility initiated a 30-day involuntary discharge for R1 without documented evidence supporting the reason. R1 exhibited verbal and behavioral symptoms directed mostly at staff, but the facility lacked documentation of interventions or incident reports. The facility also lacked a policy on involuntary discharge.

The facility was found deficient in multiple areas including failure to maintain resident dignity related to urinary catheter care, failure to accommodate resident wheelchair needs, failure to notify representatives of condition changes, incomplete care plans for scabies and catheter care, unsafe resident transfers, inadequate catheter care, failure to interpret voiding diary data, unsanitary respiratory care, incomplete staffing records, failure to submit accurate staffing data to CMS, and failure to manage residents' bowel medications appropriately.

The inspection was triggered by complaint #189595 regarding resident dignity and care issues.

The facility failed to maintain resident dignity regarding urinary catheter coverage, failed to accommodate a resident's wheelchair needs, failed to notify a resident's representative of a scabies diagnosis and treatment, failed to revise care plans for multiple residents, failed to ensure safe transfers, failed to provide sanitary catheter care, failed to analyze voiding diary data for toileting plans, failed to provide sanitary respiratory care, failed to post accurate nurse staffing data, failed to submit accurate payroll-based journal staffing data, and failed to ensure residents were free from unnecessary medications related to bowel management.

The investigation was complaint-driven, focusing on Resident 18's unmet wheelchair needs and failure to notify the resident's representative about a new scabies treatment. The complaints were substantiated with findings of minimal harm and few residents affected.

The facility failed to follow up on recommendations for a different wheelchair to meet Resident 18's physical needs and preferences, and failed to notify the resident's chosen representative about the need for new treatment related to scabies infestation. The resident was dependent on staff for transfers and used an electric wheelchair that was deteriorating.

The plan outlines corrective actions for multiple deficiencies related to resident dignity, wheelchair accommodations, care plan updates, safe transfer techniques, medication administration, and staffing data accuracy. The facility has implemented reeducation, audits, and ongoing monitoring to ensure compliance.

The facility was found deficient in providing a safe, clean, and comfortable environment, adequate ADL care, prevention of mobility decline, proper medication administration, appropriate use of psychotropic medications, quality assurance committee compliance, and infection prevention and control practices.

The facility addressed multiple deficiencies including environmental repairs, resident personal care, medication administration, restorative services, and infection control. The plan outlines corrective actions, staff education, audits, and ongoing monitoring to ensure compliance and prevent recurrence.

The facility was found deficient in multiple areas including failure to maintain a safe, clean, and comfortable environment, inadequate assistance with activities of daily living such as shaving, failure to provide restorative treatments, inconsistent medication administration, inappropriate diagnosis for antipsychotic medication, lack of required Quality Assessment and Assurance committee attendance, and failure to implement effective infection prevention measures including mask use during high COVID transmission.

The inspection was triggered by complaints regarding food preferences and meal variety for resident #2, substantiated by observations, interviews, and record reviews.

The facility failed to provide one resident with food choices that accommodated his identified preferences, resulting in dissatisfaction with meal variety and options. The resident was repeatedly served hot dogs despite expressing dislike and requesting other meal options.

The plan addresses deficiencies related to wheelchair foot pedals, bladder incontinence assessments, and implementation of dietary recommendations for residents at risk of weight loss. The facility commits to audits and staff education to ensure compliance.

The facility failed to provide wheelchair foot pedals to prevent falls for a high-risk resident, did not reassess a resident's increased urinary incontinence after hospitalization, and failed to provide timely weight loss interventions and monitoring for another resident.

The facility was found deficient in accident hazard prevention related to wheelchair foot pedals for a high fall-risk resident, failed to reassess and manage increased urinary incontinence for another resident, and did not provide timely weight loss interventions for a resident with significant weight loss.

This inspection was conducted as a complaint investigation (#153486). The complaint was substantiated based on findings of failure to follow infection control protocols related to COVID-19.

The facility failed to follow CMS and CDC recommendations to prevent COVID-19 transmission by not providing or offering face masks or tissues to five of eight sampled residents prior to direct care, increasing the risk of virus spread.

The facility was found deficient in providing face masks or tissues to residents prior to care provision, affecting five residents. The plan outlines corrective actions including training and ongoing audits to ensure compliance.

The survey was deficiency free regarding COVID-19 related compliance.

The plan outlines corrective actions for multiple deficiencies including discharge notification procedures, bed hold policy delivery, activity preferences updates, bowel protocol adherence, medication documentation, kitchen sanitation, antibiotic stewardship, and environmental cleaning.

The inspection was triggered by complaints #135251 and #136379, focusing on Medicare liability and other regulatory compliance issues.

The facility failed to provide required Medicare beneficiary protection notices, bed-hold notices, and an ongoing activities program for dependent residents. Deficiencies were found in medication management including bowel protocol adherence and psychotropic medication documentation. Food safety and sanitation issues were noted in the kitchens. The antibiotic stewardship program lacked adequate monitoring and documentation of antibiotic use.

The plan details multiple corrective actions including repairs to facility infrastructure, staff education on customer concerns and infection control, reassessment of resident needs such as glasses and lift status, and ongoing monitoring through audits and QAPI meetings.

The survey found a widespread 'F' level deficiency that constitutes no actual harm but has 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 effective 08/31/2018.

The facility failed to maintain a safe, clean, and comfortable environment in multiple resident rooms and utility areas, failed to properly investigate and resolve a resident grievance regarding staff behavior, failed to assist a resident with repairing broken glasses, failed to ensure safe transfers requiring two staff, failed to monitor and administer medications for constipation, and failed to maintain an effective infection control program with improper cleaning and storage of personal care equipment.

The survey found the facility was not in substantial compliance with participation requirements and the conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety for F678, CFR 483.24(a)(3).

The plan of correction addresses past noncompliance issues identified with tags F0000 and F678-K. No new deficiencies or corrective actions are detailed in this document.

The complaint investigation #126709 found that the facility did not initiate CPR for a resident with full code status, despite staff being CPR certified. The resident was found unresponsive with no vital signs, and staff failed to check code status before not initiating CPR.

The facility failed to provide CPR to a resident with full code status when found unresponsive, placing the resident in immediate jeopardy. The staff did not verify the resident's code status or initiate CPR as required by policy and advanced directives.

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

The facility failed to provide a full-time certified dietary manager and lacked a policy regarding the requirements for a certified dietary manager.

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 credible allegation of compliance and evidence of correction.

This plan of correction is related to a complaint investigation identified as DVC Council Grove complaint 11282016.

The plan addresses elopement risk assessments and interventions for residents, window security, staff education on elopement policy, and ongoing audits and drills to ensure compliance and resident safety.

This was a partial extended complaint investigation #107570 regarding inadequate supervision and failure to prevent elopement of a resident with dementia and exit-seeking behavior.

The facility failed to ensure adequate supervision of a cognitively impaired resident with exit-seeking behavior, who eloped multiple times through windows, including a successful elopement on 10/29/16 without staff knowledge. The care plan lacked appropriate interventions and monitoring related to the resident's elopement risk and use of a Wander guard device.

The facility was found not in substantial compliance and conditions constituted immediate jeopardy to resident health or safety from August 13, 2016 through November 18, 2016. Deficiencies cited were severe enough to warrant denial of payment for new Medicare and Medicaid admissions effective December 20, 2016.

The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report confirms that the deficiency identified under regulation 26-40-302 (b)(i)(ii)(iii)(iv)(c) with ID prefix S0966 was corrected as of 08/05/2015.

The Plan of Correction outlines corrective actions for multiple deficiencies including abuse policy compliance, care plan updates, neurological checks post-fall, restorative nursing programs, fall prevention measures, behavior intervention management, medication storage security, cleaning procedures, and emergency call light installation.

The facility had multiple deficiencies including failure to report an allegation of sexual abuse, failure to provide an ongoing program of activities meeting residents' needs, failure to revise care plans timely, failure to complete neurological checks after unwitnessed falls, failure to implement restorative nursing programs, failure to maintain fall prevention interventions, failure to monitor effectiveness of psychotropic medications with targeted behaviors, failure to secure medication carts, and failure to follow infection control cleaning protocols.

The survey found the most serious deficiency to be an 'F' level deficiency that is widespread and constitutes no actual harm but has potential for more than minimal harm without 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 survey found the most serious deficiencies to be 'E' level deficiencies, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.

The plan details corrective actions taken and scheduled to address multiple deficiencies including environmental repairs, staff education on incontinent pad use, care area assessments, care plan invitations, bowel movement protocols, medication labeling, and oxygen therapy management.

The facility had multiple deficiencies including failure to maintain resident dignity by leaving incontinent pads in common areas, inadequate housekeeping and maintenance, incomplete comprehensive assessments, failure to involve residents' families in care planning, insufficient monitoring of bowel movements, unsafe environment due to unlocked medication carts, improper labeling of insulin pens, and poor infection control practices related to nebulizer and oxygen equipment.

The report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of the revisit date. No other deficiencies or issues were noted.

The facility was found to have issues with securing harmful chemicals in locked areas to prevent resident access and potential hazards. Corrective actions include staff education, replacement and monitoring of door locks, and ongoing compliance monitoring.

The facility failed to provide an environment free from accident hazards by not securing harmful chemicals in locked areas accessible to residents. Multiple unlocked cabinets and rooms containing hazardous chemicals were observed, posing risks to cognitively impaired independently mobile residents.

The Plan of Correction addresses multiple deficiencies including inaccurate MDS assessments, improper medication administration times, expired or unlabeled food items, and medication cart labeling and outdated medications. The facility outlines corrective actions, staff education, audits, and ongoing monitoring to ensure compliance.

The plan addresses a deficiency related to accommodating a resident's food preferences and outlines corrective actions including menu updates, staff education, audits, and establishment of a Food Committee.