Inspection Reports for Diversicare of Haysville
215 N. LAMAR AVENUE, KS, 67060-1266
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 20, 2018, found the facility in compliance with all regulations and no new deficiencies. Prior inspections showed multiple deficiencies related mainly to resident care planning, notification procedures, medication management, food safety, and staffing, with several plans of correction submitted and accepted. Complaint investigations were mostly unsubstantiated, with no enforcement actions or fines listed in the available reports. Earlier reports documented issues such as fall prevention, abuse reporting, infection control, and dietary services, some resulting in citations at harm levels that were not immediate jeopardy but prompted enforcement remedies. The trend shows improvement over time, with the facility correcting prior deficiencies and achieving compliance by the most recent survey.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
36.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
507% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
107 residents
Based on a August 2018 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 20, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-08-09.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2018-09-14, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 21
Sep 8, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to ensure compliance with state and federal regulations.
Findings
The Plan of Correction details multiple deficiencies related to resident care, notification procedures, staff education, medication administration, food safety, and documentation. The facility has implemented audits, re-education, and monitoring systems to address these issues and ensure ongoing compliance.
Severity Breakdown
E: 8
D: 10
B: 1
F: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Recreation service assessments updated to assist residents in exercising the right to vote. | E |
| Proper written or advanced notice given prior to roommate changes. | E |
| Notification of dietician, physician, and family for resident weight changes. | D |
| Timely reporting of abuse/neglect/misappropriation investigations. | D |
| Notification of Office of Long Term Care Ombudsman for resident discharges. | D |
| Review and update of resident care plans. | E |
| Re-interview of residents regarding bathing, toileting, and oral hygiene with care plan updates. | E |
| Review and update of activity preferences and care plans. | E |
| Reassessment of resident skin and wound care interventions. | D |
| Fall assessments and care plan updates with education on interventions. | D |
| Annual competency evaluations for Certified Nursing Assistants completed. | E |
| Monthly in-service training and audit of CNA training completion. | D |
| Daily posting of nurse staffing information with audits. | B |
| Review and reconciliation of pharmacy recommendations by attending physician. | D |
| Documentation and monitoring of antipsychotic medication use and side effects. | E |
| Monitoring and education related to medication administration errors. | D |
| Proper storage of controlled drugs with affixed compartments. | D |
| Food holding temperatures monitored and corrected to ensure safety. | E |
| Quat sanitizer levels corrected and staff re-educated on sanitizing procedures. | F |
| Coordination of hospice services and equipment needs for residents. | D |
| Offering pneumococcal vaccination series to residents with monitoring. | D |
Report Facts
Completion Date: Sep 14, 2018
Audit frequency: 5
Audit duration: 3
Resident numbers: 265
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 21
Aug 9, 2018
Visit Reason
A Recertification Survey was conducted including investigation of complaint intake numbers KS00118819 and KS00129932, to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not in substantial compliance with multiple deficiencies including resident rights, notification of changes, abuse reporting, care planning, medication management, activities, food service, hospice coordination, and staffing.
Complaint Details
Complaint Intake Numbers KS00118819 and KS00129932 were investigated in conjunction with the recertification survey.
Severity Breakdown
SS=E: 9
SS=D: 8
SS=B: 1
: 2
Deficiencies (21)
| Description | Severity |
|---|---|
| Failure to assist residents in exercising voting rights during state primary election. | SS=E |
| Failure to provide written notice prior to roommate change for Resident 8. | SS=D |
| Failure to notify resident's physician of weight loss for Resident 72. | SS=D |
| Failure to timely report allegations of resident-to-resident abuse to State Survey Agency for Resident 19. | SS=D |
| Failure to notify Office of Long-Term Care Ombudsman of immediate transfer or discharge for Residents 23 and 40. | SS=D |
| Failure to develop and implement comprehensive care plans based on assessed needs for Residents 19, 62, 72, 81, and 98. | SS=E |
| Failure to revise care plans as needed after resident incidents and assessments for Residents 3, 19, 57, and 81. | SS=D |
| Failure to provide necessary assistance with activities of daily living including bathing and oral hygiene for Residents 35, 62, 265 and others. | SS=E |
| Failure to provide ongoing activity programs meeting resident preferences and needs for Residents 3, 35, 81 and others. | SS=E |
| Failure to provide care to prevent and treat pressure ulcers for Resident 81, including lack of care plan and delayed treatment. | SS=D |
| Failure to provide assistive devices and supervision to prevent accidents for Resident 62, including lack of transfer pole, non-skid socks, and call light within reach. | SS=D |
| Failure to ensure competency evaluations for Certified Nurse Aides CNA11 and CNA34. | SS=E |
| Failure to provide regular in-service education for Certified Nurse Aide CNA11. | SS=E |
| Failure to post daily nurse staffing data timely and accurately. | SS=B |
| Failure to ensure attending physician responded to pharmacist recommendations for medication irregularities for Residents 19 and 62. | SS=E |
| Failure to ensure Residents 19 and 62 were free from unnecessary psychotropic medications, including lack of clinical indication, monitoring, and PRN order limits. | SS=D |
| Medication error rate exceeded 5% due to improper administration of eye drops for Resident 9. | — |
| Failure to securely affix narcotic e-kit boxes to prevent unauthorized removal. | — |
| Failure to serve food at palatable temperature and maintain sanitary food service conditions. | SS=D |
| Failure to coordinate hospice services and equipment needs for Resident 62. | SS=D |
| Failure to ensure residents received second dose of pneumococcal vaccination per policy for Residents 15 and 50. | SS=D |
Report Facts
Survey Census: 107
Sample Size: 22
Medication error rate: 3
Temperature of scrambled eggs: 117
Temperature of pasta salad: 83
Temperature of pasta salad: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding multiple deficiencies and reporting | |
| Activities Director | Interviewed regarding activity program deficiencies and care planning | |
| Assistant Director of Nursing | Interviewed regarding medication administration and care planning | |
| Director of Nursing | Interviewed regarding medication regimen reviews and care coordination | |
| MDS Coordinator 1 | Interviewed regarding care planning and assessments | |
| MDS Coordinator 2 | Interviewed regarding care planning and assessments | |
| Registered Dietitian | Interviewed regarding nutritional care planning | |
| Nurse Practitioner | Interviewed regarding medication management and pneumococcal vaccination | |
| Certified Nurse Aide 57 | Interviewed regarding bathing assistance | |
| Certified Nurse Aide 87 | Interviewed regarding bathing assistance | |
| Certified Nurse Aide 11 | File reviewed for competency and inservice training | |
| Certified Nurse Aide 34 | File reviewed for competency and inservice training | |
| Corporate Dietitian | Observed food service and sanitation issues | |
| Wound Nurse | Interviewed regarding pressure ulcer care | |
| Social Services Supervisor 1 | Interviewed regarding notification and hospice coordination | |
| Nurse Aide 100 | Interviewed regarding fall risk and wheelchair safety | |
| Registered Nurse 64 | Interviewed regarding fall risk and call light placement | |
| Certified Nurse Aide/State Registered Nurse Aide 18 | Observed medication administration error |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 9, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at level 'F', 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 effective 09/14/2018.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency at level 'F', widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Named as contact person regarding the survey findings and enforcement. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 29, 2018
Visit Reason
A complaint survey was conducted on May 24th and May 29th for complaint numbers KS00129643 and KS00126378.
Findings
The allegations made in the complaints were not substantiated. No noncompliance with all regulations surveyed.
Complaint Details
The complaints were investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
May 24, 2018
Visit Reason
A complaint survey was conducted on May 24th and May 29th for complaints #KS00129643 and #KS00126378.
Findings
The allegations made in the complaints were not substantiated and no noncompliance with regulations was found.
Complaint Details
The complaints #KS00129643 and #KS00126378 were investigated and found to be not substantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 28, 2017
Visit Reason
A revisit survey was conducted on 9/26, 9/27, and 9/28/2017 to verify correction of all previous deficiencies cited on 8/29/2017.
Findings
All previously cited deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 3
Sep 12, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Findings
The plan addresses deficiencies related to physician notification following resident falls, reassessment and care planning for fall prevention, and infection control practices to prevent the spread of infection. Corrective actions include staff education, audits, interdisciplinary reviews, and ongoing monitoring through the Quality Assurance Performance Improvement (QAPI) committee.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as DVC Haysville complaint 08292017.
Severity Breakdown
D: 1
G: 1
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure physician notification of a possible injury following a fall. | D |
| Inadequate reassessment and care planning to prevent falls. | G |
| Infection control practices not adequately preventing spread of infection. | F |
Report Facts
Audit frequency: 4
Plan completion date: Sep 12, 2017
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 3
Aug 29, 2017
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding resident care and facility compliance.
Findings
The facility failed to notify the physician of a possible injury following falls for one resident, failed to provide adequate supervision and interventions to prevent falls for two residents, and lacked an effective infection control program to identify, investigate, and control infections in real-time.
Complaint Details
The inspection findings represent the results of complaint investigations #112451, #113607, #117668, #117798, #118209, #119131, and #119684.
Severity Breakdown
SS=D: 1
SS=G: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify the physician of a possible injury following falls for resident #4 who experienced two falls with left leg swelling and abnormal range of motion. | SS=D |
| Failed to provide supervision, assistive devices, and investigate causal factors to prevent future falls for residents #4 and #8, resulting in a fractured femur for resident #4. | SS=G |
| Failed to establish and maintain an effective infection prevention and control program including real-time identification, investigation, tracking, trending, and intervention of infections and communicable diseases. | SS=F |
Report Facts
Facility census: 107
Residents sampled for accidents: 4
Residents sampled: 15
Falls for resident #4: 2
Infection report sheets: 39
Infection report sheets: 25
Infection report sheets: 29
Infection report sheets: 1
Antibiotic orders: 8
Antibiotic order changes: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse A | Involved in assessment and documentation of resident #4's falls and injuries. | |
| Direct care staff B | Witnessed and assisted resident #4 during falls and reported observations. | |
| Licensed nurse C | Notified physician and arranged emergency transport for resident #4. | |
| Administrative nurse E | Provided expectations for fall reporting and infection control oversight. | |
| Physician D | Confirmed no notification received regarding resident #4's falls and injuries. | |
| Licensed nurse F | Responsible for infection control data collection and reporting. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 29, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was given.
Severity Breakdown
Level of actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at a level of actual harm that is not immediate jeopardy | Level of actual harm |
Report Facts
Denial of payment effective date: Sep 18, 2017
Previous survey date: Jun 29, 2017
Termination recommendation date: Mar 1, 2018
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Lisa Hauptman | CMS contact for questions regarding the matter |
Inspection Report
Follow-Up
Deficiencies: 5
Jul 25, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.12(a)(3)(4)(c)(1)-(4), 483.12(b)(1)-(3), 483.95(c)(1)-(3), 483.20(d), 483.21(b)(1), 483.50(a)(1), and 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i) were corrected as of 07/06/2017.
Deficiencies (5)
| Description |
|---|
| Deficiency identified under regulation 483.12(a)(3)(4)(c)(1)-(4) |
| Deficiency identified under regulation 483.12(b)(1)-(3), 483.95(c)(1)-(3) |
| Deficiency identified under regulation 483.20(d); 483.21(b)(1) |
| Deficiency identified under regulation 483.50(a)(1) |
| Deficiency identified under regulation 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 5
Jul 6, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a revised complaint investigation involving allegations of verbal abuse and deficiencies in care planning and laboratory services.
Findings
The plan addresses alleged verbal abuse involving Resident #1, development and implementation of Abuse/Neglect/Misappropriation policies, comprehensive care plan deficiencies, lab order monitoring, and Quality Assurance Performance Improvement (QAPI) processes. Resident #1 is no longer in the facility.
Complaint Details
The plan of correction responds to a revised complaint involving alleged verbal abuse of Resident #1. The investigation was completed and sent to KDADS on 6/9/17. Resident #1 is no longer in the center.
Severity Breakdown
F: 3
D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Alleged verbal abuse involving Resident #1 | F225-F |
| Failure to develop and implement Abuse/Neglect/Misappropriation policy | F226-F |
| Failure to develop comprehensive care plans | F279-D |
| Failure to ensure lab orders were completed as ordered | F502-D |
| Quality Assurance and Performance Improvement (QAPI) process deficiencies | F520-F |
Report Facts
Audit frequency: 5
Audit frequency: 5
Completion date: Jul 6, 2017
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 5
Jun 29, 2017
Visit Reason
The inspection was a partial extended survey conducted for complaint investigation #116615 regarding allegations of staff-to-resident verbal abuse and other compliance issues.
Findings
The facility failed to ensure staff reported an allegation of staff-to-resident verbal abuse to the administrator and State agency, failed to protect residents from potential abuse, and failed to complete a thorough investigation. Additionally, the facility failed to develop comprehensive care plans for two residents, failed to provide laboratory services as ordered for one resident, and failed to ensure physician attendance at Quality Assurance meetings.
Complaint Details
The complaint investigation was triggered by an allegation of staff-to-resident verbal abuse involving licensed nurse staff A and resident #1. The facility failed to report the allegation timely to administration and the State, failed to protect residents, and failed to conduct a thorough investigation.
Severity Breakdown
SS=F: 3
SS=D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to report and investigate allegations of staff-to-resident verbal abuse and failed to protect residents from potential abuse. | SS=F |
| Failed to develop and implement abuse/neglect policies and procedures including staff training. | SS=F |
| Failed to develop comprehensive care plans for residents including measurable objectives and timeframes. | SS=D |
| Failed to provide or obtain laboratory services as ordered by the physician. | SS=D |
| Failed to ensure physician attendance at Quality Assurance meetings at least quarterly. | SS=F |
Report Facts
Census: 101
Deficiencies cited: 5
BIMS score: 15
BIMS score: 13
Lab testing frequency: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse staff A | Licensed Nurse | Named in verbal abuse allegation involving resident #1. |
| Licensed nurse staff S | Licensed Nurse | Received verbal abuse allegation report but failed to investigate or report it. |
| Administrative staff L | Facility administrator involved in investigation and interview regarding abuse allegation. | |
| Administrative nursing staff C | Administrative Nursing Staff | Interviewed regarding abuse allegation and lab services; confirmed lack of investigation and reporting. |
| Administrative staff T | Interviewed regarding facility policy and failure to report abuse allegation. | |
| Administrative nursing staff J | Administrative Nursing Staff | Interviewed about care plan completion timelines and lack of comprehensive care plans. |
| Physician extender P | Physician Extender | Interviewed regarding lab testing orders and management. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 29, 2017
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety. Deficiencies cited were severe enough to warrant denial of payment for new Medicare and Medicaid admissions and recommendation for termination of the provider agreement if substantial compliance is not achieved.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F225, "L", CFR 483.12(a)(3)(4)(c)(1)-(4) and F226, "F", CFR 483.12(b)(1)-(3),483.95(c)(1)-(3) | Immediate Jeopardy |
Report Facts
Denial of payment effective date: Jul 25, 2017
Recommended termination date: Dec 29, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the survey and enforcement actions |
Inspection Report
Plan of Correction
Deficiencies: 12
Mar 10, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility to address and correct alleged deficiencies identified during a prior inspection.
Findings
The plan outlines corrective actions taken or planned for multiple deficiencies including environmental issues, MDS assessment accuracy, care plan revisions, pressure ulcer prevention, accident hazards, drug regimen reviews, medication record updates, infection control, medication storage, and nursing facility support systems. Education, audits, and ongoing monitoring through the QAPI committee are described for each deficiency.
Deficiencies (12)
| Description |
|---|
| Environmental items discussed during the exit have been addressed and education was provided for the Environmental Services staff. |
| Resident #139 MDS have been reviewed and updated; interdisciplinary team re-educated on MDS assessment accuracy. |
| Resident #63 and #18 care plans reviewed and updated based on resident preferences; interdisciplinary team re-educated on care plan revisions. |
| Residents' dietitian recommendations reviewed and interventions put in place to prevent/heal pressure ulcers. |
| Resident #63 care plans reviewed and revised; facility will complete group reviews after falls to prevent future falls. |
| Consultant pharmacists reviewed drug regimens for residents #88 and #105 to identify and reduce unnecessary drugs. |
| Medication carts and treatment carts checked; expired or undated medications removed; nurses educated on medication storage. |
| Medication records for residents #53, #88, #139, and #74 reviewed and updated to include units given; education on insulin administration provided. |
| Pharmacy MAR review conducted for residents #105 and #139 to identify drug irregularities; education provided to consultant pharmacist. |
| Dietary and nursing staff re-educated on infection control practices; audits of sanitary environment and infection control use implemented. |
| Medication storage room temperature lowered and monitoring implemented; programmable thermostats installed to prevent unauthorized changes. |
| Nurse call stations installed and pull cords positioned within reach in bathing areas; emergency call lights audited and additional lights installed. |
Report Facts
Audit frequency: 5
Audit duration: 3
Audit frequency: 3
Audit frequency: 3
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Vanhook | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 11
Mar 10, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed by regulation numbers were marked as corrected and completed as of the revisit date.
Deficiencies (11)
| Description |
|---|
| Deficiency with regulation 483.15(h)(2) |
| Deficiency with regulation 483.20(g)-(j) |
| Deficiency with regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency with regulation 483.25(c) |
| Deficiency with regulation 483.25(h) |
| Deficiency with regulation 483.25(l) |
| Deficiency with regulation 483.35(i) |
| Deficiency with regulation 483.60(a),(b) |
| Deficiency with regulation 483.60(c) |
| Deficiency with regulation 483.60(b),(d),(e) |
| Deficiency with regulation 483.65 |
Inspection Report
Re-Inspection
Deficiencies: 2
Mar 10, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Diversicare of Haysville have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 28-39-156(d) and 26-40-302 (b)(i)(ii)(iii)(iv)(c) have been corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 28-39-156(d) |
| Deficiency related to regulation 26-40-302 (b)(i)(ii)(iii)(iv)(c) |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 10, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
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 effective March 10, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Mar 10, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated acceptance of plan of correction |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 2
Jan 26, 2017
Visit Reason
The inspection was conducted as a Health Licensure Resurvey and Complaint Investigations related to multiple complaint numbers.
Findings
The facility failed to maintain appropriate medication room temperature, allowing it to reach 90.3 degrees Fahrenheit, and failed to have emergency call buttons or pull cords within resident reach in shower and whirlpool areas on the 400 and 500 halls.
Complaint Details
The visit included complaint investigations #111389, 110927, 110082, 109647, 109478, 106179, 100373, 96964, 96574, 96080, and 95475.
Severity Breakdown
SS=F: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain medication room temperature within acceptable range, temperature measured 90.3 degrees Fahrenheit. | SS=F |
| Failed to have emergency call button or pull cord within resident reach next to each shower or whirlpool in the 400 and 500 halls. | SS=E |
Report Facts
Facility census: 113
Medication room temperature: 90.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MM | Licensed nursing staff | Reported medication room temperature concerns |
| D | Administrative nursing staff | Reported medication room temperature issue and call light cord accessibility |
| S | Licensed nursing staff | Moved medications to central supply room after temperature discovery |
| HH | Administrative nursing staff | Moved medications to central supply room after temperature discovery |
| FF | Maintenance staff | Reported lack of knowledge on temperature monitoring and confirmed call light cord issues |
Inspection Report
Follow-Up
Deficiencies: 2
Jan 11, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiencies previously cited under regulations 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) and 483.25(d)(1)(2)(n)(1)-(3) were corrected as of 01/01/2017.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) |
| Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3) |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 2
Dec 22, 2016
Visit Reason
Complaint investigation KS00109161 was conducted to evaluate the facility's compliance with resident care planning and accident prevention requirements.
Findings
The facility failed to revise the care plan for one resident to include interventions after multiple falls and did not evaluate the effectiveness of interventions. The resident fell three times without wearing non-skid socks as care planned, resulting in a hip fracture. The facility also failed to maintain a sign reminding the resident to use the call light and did not ensure adequate supervision and fall prevention measures.
Complaint Details
The inspection was conducted as a complaint investigation (KS00109161) focusing on resident care planning and accident prevention related to falls.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to revise the care plan for a resident to include interventions developed after two falls and failed to evaluate the effectiveness of current interventions. | SS=D |
| Failed to implement appropriate, effective interventions to prevent falls for a resident who fell three times without wearing non-skid socks, resulting in a hip fracture. | SS=G |
Report Facts
Census: 115
Resident sample size: 3
Falls: 3
Date of falls: Falls occurred on 9/23/16, 10/28/16, and 12/1/16 as per fall analysis worksheets.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Reported that gripper socks were not effective unless used and that the resident's care plan should have been revised to ensure a sign was posted in the resident's room. | |
| Direct care staff D | Reported the resident sometimes slept with gripper socks on and described the sign reminding the resident to use the call light. | |
| Licensed nursing staff E | Reported staff needed to answer call light promptly and supervise the resident to ensure gripper socks were worn correctly. | |
| Therapy staff F | Reported the resident was receiving therapy at the time of the fall and that gripper socks were available but the call light sign was missing in the long term care unit. |
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 22, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at the facility.
Findings
The plan addresses deficiencies related to resident #3's care plan, specifically regarding fall prevention interventions and post-fall assessments. The facility outlines corrective actions including care plan reviews, staff reeducation, and ongoing monitoring by the Director of Nursing and interdisciplinary teams.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as DVC Haysville complaint 12222016.
Severity Breakdown
D: 1
G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #3 Care Plan has been reviewed and revised as appropriate to address fall interventions. | D |
| Resident #3's Care Plan has been reviewed to ensure appropriate interventions are in place after falls. | G |
Report Facts
Complete Date: Jan 1, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Dec 22, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be F323, CFR 483.25(d)(1)(2)(n)(1)-(3), rated 'G' at a level of actual harm that is not immediate jeopardy. Based on these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions effective January 11, 2017.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency F323, CFR 483.25(d)(1)(2)(n)(1)-(3), rated 'G' at a level of actual harm that is not immediate jeopardy | G |
Report Facts
Denial of payment effective date: Jan 11, 2017
Compliance deadline: Jun 22, 2017
Civil Money Penalty minimum amount: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to instructions for informal dispute resolution and contact for questions |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 7, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Findings
The facility was found deficient in providing sufficient preparation and orientation to residents to ensure safe and orderly transfer from the facility. The plan outlines education provided to licensed nurses and Social Services staff and auditing procedures to ensure compliance.
Complaint Details
Related to a complaint investigation as indicated by the reference to 'DVC Haysville complaint 07282016'.
Deficiencies (1)
| Description |
|---|
| The facility will provide sufficient preparation and orientation to residents to ensure safe and orderly transfer from this facility. |
Report Facts
Audit frequency: 3
Audit duration: 4
Inspection Report
Follow-Up
Deficiencies: 1
Aug 7, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with regulation 483.12(a)(7) was corrected as of 08/07/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.12(a)(7) |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jul 28, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
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 which was accepted, and the facility was found to be in substantial compliance effective August 7, 2016.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Jul 28, 2016
Visit Reason
The inspection was conducted as an investigation of complaints #3390 and #2348 regarding the facility's discharge planning process.
Findings
The facility failed to ensure staff developed and implemented discharge planning for a resident after issuing a 30-day discharge notice. The resident remained in the facility beyond the discharge date and expressed fear and uncertainty about the discharge. The facility eventually transferred the resident out of state without involving any relatives in the discharge planning. Documentation showed incomplete discharge planning and lack of physician signature on initial orders.
Complaint Details
Investigation of complaints #3390 and #2348. The complaint was substantiated as the facility failed to develop and implement a discharge plan for resident #1 after issuing a 30-day discharge notice.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff developed and implemented discharge planning for resident #1 after issuing a 30-day discharge notice. | SS=D |
Report Facts
Facility census: 111
Discharge notice date: Jun 23, 2016
Resident transfer date: Jul 23, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Staff B | Social Service Staff | Reported details about the resident's transfer and discharge planning. |
| Administrative Staff C | Administrative Staff | Communicated about the resident's transfer and Medicaid process. |
Inspection Report
Life Safety
Deficiencies: 1
Jun 6, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at 'F' level, indicating no harm with potential for more than minimal harm but 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Sep 6, 2016
Provider agreement termination date: Dec 6, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact for informal dispute resolution process |
Inspection Report
Follow-Up
Deficiencies: 5
Jan 11, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously cited deficiencies identified by regulation numbers F0223, F0225, F0226, F0272, and F0431 were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency identified under regulation 483.13(b), 483.13(c)(1)(i) |
| Deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency identified under regulation 483.13(c) |
| Deficiency identified under regulation 483.20(b)(1) |
| Deficiency identified under regulation 483.60(b), (d), (e) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 5
Nov 20, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to alleged deficiencies identified in a complaint investigation.
Findings
The plan addresses multiple deficiencies related to resident care, abuse prevention, care area assessments, and medication storage. Corrective actions include resident observation, care plan updates, staff re-education, policy revisions, audits, and ongoing monitoring through QAPI meetings.
Severity Breakdown
D: 2
K: 1
F: 1
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident #4 was placed on 1:1 observation and discharged to the behavior unit; care plans for residents #1, #4, and #9 were reviewed and updated; staff re-educated on Abuse, Neglect and Misappropriation Policy and Elder Justice Act. | D |
| Administrator reviewed all possible or alleged incidents of Abuse, neglect, and misappropriation in the last 90 days for trends; ongoing monthly review planned. | K |
| Abuse, Neglect, and Misappropriation policy revised to include protection for all residents; staff re-education and monthly interviews planned for 3 months. | F |
| Care Area Assessment for resident #1 completed; audit of comprehensive assessments in last 30 days to identify and complete incomplete care area assessments; staff re-education and ongoing review planned. | D |
| Licensed Nurse L re-educated on medication storage and locking medication carts; staff re-educated; audits of medication carts locking 3 times a week for 1 month planned. | E |
Report Facts
Corrective action completion date: Nov 20, 2015
Medication cart audit frequency: 3
Audit duration: 30
Interview duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse L | Licensed Nurse | Re-educated on medication storage and locking medication carts |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 6
Nov 19, 2015
Visit Reason
Partial extended abbreviated survey conducted for complaint investigation #92881 regarding allegations of resident-to-resident sexual abuse and inappropriate touching.
Findings
The facility failed to ensure resident #1 remained free from sexual abuse by resident #4, failed to immediately report and thoroughly investigate incidents of sexual abuse, and failed to protect other residents from potential abuse. The facility also failed to complete a comprehensive assessment for resident #1 and failed to securely store medications on one medication cart.
Complaint Details
Complaint investigation #92881 focused on allegations of sexual abuse and inappropriate touching by resident #4 towards resident #1. Multiple staff interviews and record reviews confirmed incidents of inappropriate touching and failure to protect residents. The facility failed to report the initial incident timely to the State Agency and failed to protect other residents at risk. Additional resident-to-resident abuse incident involving resident #9 and resident #2 was also not properly investigated.
Deficiencies (6)
| Description |
|---|
| Failed to ensure resident #1 remained free from sexual abuse by resident #4. |
| Failed to immediately report, investigate, and protect residents from sexual abuse incidents involving resident #4. |
| Failed to investigate an incident of resident-to-resident abuse by resident #9 to resident #2. |
| Failed to develop and implement written policies and procedures that include protection of residents from other residents regarding abuse, neglect, and exploitation. |
| Failed to complete a comprehensive assessment including the Psychosocial Well-Being care area assessment for resident #1. |
| Failed to securely store medications on one medication cart which was found unlocked and unattended. |
Report Facts
Residents present: 102
Medication carts observed: 5
Inappropriate touching incidents known: 3
Date of initial sexual abuse incident: Jul 19, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Direct Care Staff | Reported initial sexual abuse incident on 7/19/15 and wrote witness statement |
| Staff G | Dietary Staff | Witnessed sexual abuse incident on 7/19/15 and reported to nurse |
| Licensed Nurse O | Licensed Nurse | Consulted by Staff N on 7/19/15 and advised reporting procedures |
| Licensed Nurse E | Licensed Nurse | Reported multiple incidents of inappropriate touching and notified administrative nurse |
| Administrative Nurse F | Administrative Nurse | Received reports of incidents, responsible for reporting to State Agency |
| Administrative Staff J | Administrative Staff | Involved in handling incidents and acknowledged lack of protective plan |
| Staff C | Social Services Staff | Reported resident interactions and family involvement |
| Staff A | Direct Care Staff | Informed to keep resident #1 away from resident #4 |
| Staff B | Direct Care Staff | Reported nursing meeting on abuse policies and monitoring resident #4 |
| Licensed Nurse I | Licensed Nurse | Reported multiple incidents of inappropriate touching to administration |
| Licensed Nurse D | Licensed Nurse | Reported inappropriate touching and resident separation |
| Licensed Nurse K | Administrative Nurse | Reported on MDS assessments and care area assessments |
| Licensed Nurse L | Licensed Nurse | Observed medication cart unlocked and unattended |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Nov 19, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not in substantial compliance, with conditions constituting immediate jeopardy to resident health or safety from July 19, 2015 through November 6, 2015. Deficiencies cited included F225 and F226 related to substandard quality of care.
Severity Breakdown
Immediate Jeopardy: 1
Substandard Quality of Care: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Noncompliance with F225, CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) | Immediate Jeopardy |
| Noncompliance with F226, CFR 483.13(c) | Substandard Quality of Care |
Report Facts
Denial of payment effective date: Dec 21, 2015
Provider agreement termination recommended date: May 19, 2015
Civil Money Penalty minimum amount: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named in relation to the findings and instructions for informal dispute resolution |
Inspection Report
Plan of Correction
Deficiencies: 8
Oct 30, 2015
Visit Reason
This document is a Plan of Correction submitted by Diversicare Haysville in response to deficiencies cited in complaint investigations.
Findings
The plan outlines corrective actions for multiple deficiencies related to care plan revisions after falls, meal service timeliness, food temperature monitoring, therapeutic diet management, and kitchen sanitation. The facility commits to staff education, audits, and ongoing compliance monitoring through the QAPI committee.
Severity Breakdown
D: 4
F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Resident #3 and #4 Care Plan was reviewed and revised as appropriate related to falls. | D |
| Resident #1 Care Plan was reviewed and revised as appropriate related to initial care plans and CNA care cards. | D |
| Resident #1, 3, and 4 Care Plans were reviewed and revised as appropriate with post-fall investigations. | D |
| Resident food trays will be delivered in designated time frames for meal service. | F |
| Facility will monitor food temperatures and timely serving of food to ensure palatable foods at correct temperatures. | F |
| Resident #2, 5, and 6 dietary orders were reviewed and revised as appropriate for therapeutic diets. | D |
| Facility cleaned kitchen equipment and addressed temperature logs; staff educated on sanitation. | F |
| Center policies and procedures reviewed and staff educated on food temperatures, kitchen cleanliness, fall investigations, and care plan revisions. | F |
Report Facts
Plan of Correction completion date: Oct 30, 2015
Audit duration: 3
Sanitation audits frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | Listed as contact person for Plan of Correction assistance |
| Weston Parsons | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Oct 30, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected as of the revisit date.
Findings
The report confirms that the previously cited deficiency with regulation number 26-43-101(g) and ID prefix S2030 was corrected on 10/30/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency identified by regulation 26-43-101(g) with ID prefix S2030 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 6
Oct 2, 2015
Visit Reason
Complaint investigations were conducted related to care plan revisions, fall prevention, dietary services, and sanitary conditions at Diversicare of Haysville.
Findings
The facility failed to review and revise care plans after resident falls, failed to provide adequate supervision to prevent falls, failed to provide therapeutic diets as prescribed, failed to serve meals timely and at proper temperatures, and failed to maintain sanitary conditions in the kitchen including inadequate cleaning and improper food handling.
Complaint Details
The inspection was triggered by multiple complaint investigations (#KS00091425, #KS00090743, #KS00090572, #KS000089983) focusing on care plan revisions after falls, dietary services, and sanitary conditions.
Severity Breakdown
SS=D: 4
SS=F: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to review/revise care plans for residents after falls, including measurable goals and interventions. | SS=D |
| Failed to provide adequate supervision and fall prevention strategies for residents with fall history. | SS=D |
| Failed to have sufficient dietary staff to serve meals timely in dining room and via room trays. | SS=F |
| Failed to provide palatable foods at proper temperatures; staff failed to take temperatures of all foods prior to meal service and hot foods cooled during prolonged meal service. | SS=F |
| Failed to provide therapeutic diets as prescribed by physicians for residents with special dietary needs. | SS=D |
| Failed to maintain sanitary conditions in kitchen including inadequate cleaning, improper handling of clean dishes and sugar bin contamination, and failure to monitor refrigerator/freezer temperatures twice daily. | SS=F |
Report Facts
Residents sampled: 6
Residents census: 111
Falls for resident #4: 3
Meal service delay: 50
Meal service delay: 75
Temperature of pimento cheese sandwiches: 60
Temperature of fried okra: 108
Temperature of sliced ham: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Reported on fall incidents and lack of care plan revisions. |
| Administrative Nurse J | Administrative Nurse | Reported nurses' responsibility for fall investigations and confirmed lack of care plan revisions. |
| Licensed Nurse I | Licensed Nurse | Reported resident #1 needed 1:1 care and fall supervision. |
| Dietary Staff C | Dietary Staff | Reported on meal menu procedures and temperature monitoring failures. |
| Dietary Staff D | Dietary Staff | Observed preparing meals and failed to take food temperatures. |
| Dietary Staff E | Dietary Staff | Observed preparing meals and failed to take temperatures of all foods. |
| Dietary Staff F | Dietary Staff | Reported not taking food temperatures prior to meal service. |
| Dietary Staff G | Dietary Staff | Reported lack of knowledge about temperature monitoring requirements. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Oct 2, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies that constitute no actual harm 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 and the plan of correction.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 27, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation numbers and prefix codes were corrected by 07/26/2015 as documented in this revisit report.
Report Facts
Deficiencies corrected: 13
Inspection Report
Plan of Correction
Deficiencies: 11
Jul 26, 2015
Visit Reason
This document is a Plan of Correction submitted by Diversicare Of Haysville in response to deficiencies cited during a prior inspection.
Findings
The plan outlines corrective actions taken or planned to address multiple deficiencies related to resident care plans, activity services, medication management, dietary services, and facility safety. The facility describes staff education, monitoring, and auditing processes to ensure compliance and ongoing quality assurance.
Severity Breakdown
D: 6
G: 1
E: 2
F: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Use of correct discharge form (NOMNC CMS 10123) for residents ending skilled services | D |
| Provision of tub bath option for residents | D |
| Ensuring activities staff follow resident preferences for one-on-one activities | D |
| Review and update of individualized resident care plans | D |
| Monitoring skin integrity and dialysis documentation | D |
| Management of urinary incontinence and bladder diary completion | D |
| Nutritional status monitoring and weight loss interventions | G |
| Timely delivery of resident food trays | E |
| Sanitation and food handling practices in dietary department | F |
| Medication storage issues including unlocked e-kit, expired medication, and undated insulin pen | E |
| Implementation of QAPI process with root cause analysis and action plans | F |
Report Facts
Audit frequency: 3
Audit frequency: 10
Audit frequency: 5
Completion date: Jul 26, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Weston Parsons | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction document |
Inspection Report
Census: 107
Deficiencies: 13
Jun 29, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations to assess compliance with federal regulations.
Findings
The facility was cited for multiple deficiencies including failure to provide correct Medicare non-coverage notices, failure to honor resident bathing choices, inadequate activities programming, incomplete care plans, failure to monitor dialysis patients properly, failure to manage urinary incontinence, severe unaddressed weight loss in a resident, insufficient dietary staffing, unsanitary food handling practices, and medication storage and labeling issues.
Severity Breakdown
SS=D: 8
SS=E: 2
SS=F: 2
SS=G: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide CMS approved Medicare non-coverage forms to three of five residents. | SS=D |
| Failed to honor bathing choices for 2 of 3 residents; tub bath preference not accommodated due to non-working tub. | SS=D |
| Failed to provide activities to meet interests and needs for 1 resident. | SS=D |
| Failed to develop comprehensive care plans for 3 residents. | SS=D |
| Failed to review and revise care plan for 1 resident to reflect removal of non-skid strips. | SS=D |
| Failed to identify and assess skin scabbed sore on resident's nose and provide care and monitoring. | SS=D |
| Failed to provide care and monitoring prior to and after dialysis treatments for resident. | SS=D |
| Failed to monitor, review, and revise approaches to care essential to managing urinary incontinence for 1 resident. | SS=D |
| Failed to maintain acceptable nutritional status and implement adequate nutritional interventions for resident with severe weight loss. | SS=G |
| Failed to ensure sufficient dietary staffing to allow residents to eat meals at the time of their choosing. | SS=E |
| Failed to store and serve food under sanitary conditions including failure to date perishable foods, improper hand hygiene, inappropriate footwear, and inadequate hair restraints. | SS=F |
| Failed to label insulin pens with opened and discard dates, discard expired medication, and lock emergency medication kit. | SS=E |
| Failed to develop and implement an effective Quality Assessment and Assurance (QAA) program to identify and correct quality deficiencies. | SS=F |
Report Facts
Resident census: 107
Residents reviewed: 28
Weight loss percentage: 26.5
Weight loss pounds: 50
Weight loss pounds: 39
Weight loss percentage: 23.33
Weight measurements: 177
Weight measurements: 138
Weight measurements: 188
Weight measurements: 185
Weight measurements: 161
Weight measurements: 144
Weight measurements: 143
Weight measurements: 138
Medication administration days: 3
Meal service times: 7
Residents assisted simultaneously: 4
Weight loss percentage: 23.33
Weight loss percentage: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Social Services | Verified incorrect Medicare non-coverage forms were distributed |
| Staff K | Direct Care Staff | Reported resident bathing preferences and activities |
| Staff N | Licensed Nursing Staff | Reported bathing preferences assessment and tub availability |
| Staff I | Maintenance Staff | Reported tub replacement bids and tub condition |
| Staff A | Administrative Nursing Staff | Reported bathing preferences and tub replacement history |
| Staff M | Activities Staff | Reported resident activity participation and assessments |
| Staff N | Licensed Nursing Staff | Reported resident activity and communication |
| Staff C | Administrative Staff | Confirmed care plan deficiencies |
| Staff S | Therapy Staff | Reported resident therapy and transfer needs |
| Staff AA | Licensed Nurse | Reported resident denture care and meal assistance |
| Staff E | Licensed Nursing Staff | Reported skin assessments and unaware of scabbed area |
| Staff U | Licensed Nursing Staff | Reported skin assessment procedures and orders |
| Staff GG | Direct Care Staff | Reported dialysis care procedures |
| Staff HH | Direct Care Staff | Reported vital sign monitoring procedures |
| Staff JJ | Licensed Nurse | Reported dialysis care procedures |
| Staff P | Direct Care Staff | Reported emergency kit lock procedures |
| Staff CC | Licensed Staff | Reported expired medication in refrigerator |
| Staff BB | Licensed Staff | Reported insulin pen labeling and discard procedures |
| Staff V | Direct Care Staff | Reported dining assistance staffing and meal timing |
| Staff Q | Dietary Staff | Reported kitchen staffing and food handling practices |
| Staff X | Direct Care Staff | Reported resident continence and toileting assistance |
| Staff Z | Direct Care Staff | Reported resident continence and toileting assistance |
| Staff AA | Licensed Nurse | Reported nutritional interventions and resident assistance |
| Staff FF | Dietary Staff | Reported kitchen dress code and food handling practices |
| Staff J | Dietary Staff | Reported kitchen dress code and food handling practices |
| Staff DD | Dietary Staff | Reported kitchen dress code and food handling practices |
| Staff B | Administrative Staff | Reported kitchen dress code and food handling practices |
| Staff A | Administrative Nursing Staff | Reported QAA committee functions and quality concerns |
| Physician KK | Physician | Reported unawareness of resident weight loss and expectations |
| Registered Dietician F | Dietician | Reported nutritional assessments and interventions |
Inspection Report
Enforcement
Deficiencies: 0
Jun 29, 2015
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, with deficiencies cited on this survey and a prior abbreviated survey on June 13, 2014. Due to the history of noncompliance, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.
Report Facts
Denial of payment effective date: Jul 27, 2015
Noncompliance correction deadline: Dec 29, 2015
Civil Money Penalty threshold: 5000
Prior survey date: Jun 13, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Thomas | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions regarding the enforcement action |
Inspection Report
Follow-Up
Deficiencies: 8
Aug 7, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that all previously cited deficiencies were corrected by 07/13/2014 as verified during the revisit on 08/07/2014.
Deficiencies (8)
| Description |
|---|
| Deficiency identified under regulation 483.10(f)(2) |
| Deficiency identified under regulation 483.15(a) |
| Deficiency identified under regulations 483.20(d), 483.20(k)(1) |
| Deficiency identified under regulation 483.25(c) |
| Deficiency identified under regulation 483.25(k) |
| Deficiency identified under regulation 483.30(a) |
| Deficiency identified under regulation 483.35(i) |
| Deficiency identified under regulation 483.65 |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Jul 13, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a complaint investigation, outlining corrective actions to address alleged deficiencies.
Findings
The facility identified multiple deficiencies related to grievance resolution, dignity and respect of individuality, care plan development, pressure sore treatment, special needs care, nursing staff sufficiency, food sanitation, and infection control. The Plan of Correction details policy reviews, staff in-services, audits, and monitoring procedures to ensure compliance and improvement.
Severity Breakdown
E: 3
D: 2
F: 2
G: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Right to Prompt Efforts to resolve Grievances | E |
| Dignity and Respect of Individuality | E |
| Develop Comprehensive Care Plans | D |
| Treatment/Services to Prevent/Heal Pressure Sores | G |
| Treatment/Care for Special Needs | D |
| Sufficient 24-Hour Nursing Staff per Care Plans | F |
| Food Procure, Store/Prepare/Serve-Sanitary | E |
| Infection Control, Prevent Spread, Linens | F |
Report Facts
Completion Date: Jul 13, 2014
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 8
Jun 13, 2014
Visit Reason
Complaint survey for complaints #75661, #75523, #75526 and #75447 regarding resident grievances, dignity and respect, care planning, pressure sore treatment, respiratory care, staffing, food sanitation, and infection control.
Findings
The facility failed to promptly resolve resident grievances, provide dignified care related to room tray removal, develop comprehensive care plans for respiratory care, and adequately treat pressure ulcers leading to deterioration and hospitalization. The facility also failed to maintain sufficient staffing to meet resident care needs, serve fluids in a sanitary manner, and implement an effective infection control program for a resident with respiratory MRSA.
Complaint Details
The survey was conducted in response to complaints #75661, #75523, #75526, and #75447.
Severity Breakdown
SS=E: 3
SS=D: 2
SS=G: 1
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to have a system to ensure prompt efforts to resolve resident grievances including missing personal items. | SS=E |
| Failed to provide dignified care by not removing room trays in a timely manner for residents who requested room trays. | SS=D |
| Failed to develop a comprehensive care plan addressing respiratory care for an oxygen-dependent resident with COPD. | SS=G |
| Failed to adequately assess, develop, and implement interventions to prevent and treat pressure ulcers, resulting in deterioration and hospitalization. | SS=D |
| Failed to provide proper respiratory care including lack of current physician orders for oxygen and inadequate cleaning of nebulizer and oxygen equipment. | SS=F |
| Failed to provide sufficient nursing staff to meet resident care plans and needs, resulting in delayed care and unmet resident requests. | SS=E |
| Failed to ensure fluids were served in a sanitary manner by not routinely cleaning reusable water pitchers and cups. | SS=F |
| Failed to establish an effective infection control program for a resident with respiratory MRSA, including lack of isolation and improper ice handling procedures. | SS=F |
Report Facts
Residents in sample: 15
Residents requesting room trays: 35
Pressure ulcer measurements: 5
Oxygen flow rate: 3
Medication orders: 2
Beds not made: 14
Beds not made: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Provided statements regarding respiratory care and infection control | |
| Administrative staff K | Provided statements regarding grievance system and staffing adequacy | |
| Licensed nurse H | Described oxygen equipment cleaning practices | |
| Direct care staff C | Observed assisting resident's roommate and handling meal service | |
| Direct care staff I | Described water pitcher use and cleaning practices |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 13, 2014
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be a 'G' level related to noncompliance with F314, Pressure Ulcers. Enforcement remedies including denial of payment for new Medicare admissions were imposed due to failure to achieve substantial compliance.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F314, Pressure Ulcers | G |
Report Facts
Denial of payment effective date: Sep 11, 2014
Termination recommendation date: Dec 11, 2014
Civil Money Penalty minimum amount: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonio Thomas | Administrator | Named as facility administrator |
| Mary Jane Kennedy | LBSW, Complaint Coordinator | Contact person for questions concerning the letter |
Inspection Report
Life Safety
Deficiencies: 1
Jun 11, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but with potential for more than minimal harm, not constituting immediate jeopardy.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were 'F' level, widespread, with no harm but potential for more than minimal harm. | F |
Report Facts
Effective date for denial of payments: Sep 11, 2014
Provider agreement termination date: Dec 11, 2014
Plan of Correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator for the Kansas Department for Aging and Disability Services. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Jun 4, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that the deficiency identified under regulation 483.25(l) with ID prefix F0329 was corrected as of 06/04/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(l) previously cited and corrected. |
Report Facts
Deficiency correction date: Jun 4, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 2, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited related to the use of unnecessary drugs, specifically antipsychotic medications.
Findings
The facility identified issues with the use of antipsychotic medications, including inappropriate dosage and documentation. The plan outlines corrective actions including staff education, audits, and ongoing monitoring to ensure compliance with medication regulations.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Drug regimen is free from unnecessary drugs | D |
Report Facts
Compliance date: Jun 2, 2014
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 3
May 5, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#74670) focusing on the use of antipsychotic medications and related care practices at the facility.
Findings
The facility failed to ensure appropriate dosing, monitoring, and use of non-pharmacological interventions prior to administering antipsychotic medications for residents. Specifically, residents received excessive doses without adequate monitoring or attempts at behavioral interventions. Additionally, there was a lack of proper medication orders and documentation for antipsychotic dose changes.
Complaint Details
Complaint investigation #74670 focused on the use of unnecessary antipsychotic drugs and related care practices.
Deficiencies (3)
| Description |
|---|
| Failure to ensure residents received appropriate doses of antipsychotic medications, adequate monitoring for side effects, and attempts at non-pharmacological interventions prior to medication use. |
| Resident #1's Seroquel dose was increased 400% without documented non-pharmacological interventions or adequate monitoring for side effects, leading to increased lethargy and hospitalization. |
| Resident #2 had discrepancies in Risperdal dosing orders, including an undocumented increase from 1 mg to 2 mg and lack of proper medication order documentation. |
Report Facts
Facility census: 112
Residents reviewed for unnecessary medications: 3
Seroquel dose increase: 400
BIMS score: 4
BIMS score: 5
Antipsychotic medication days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Nursing Staff | Provided information on monitoring expectations, medication order processes, and facility policies. |
| Staff B | Direct Care Staff | Reported resident confusion and lethargy near end of stay. |
| Staff C | Licensed Nursing Staff | Reported resident refusal of care and medications, and described resident behavior. |
| Staff D | Licensed Nursing Staff | Described monitoring for side effects and behaviors. |
| Staff E | Licensed Nursing Staff | Processed medication orders and discussed family concerns about drowsiness. |
| Staff F | Social Services Staff | Described resident behaviors and family concerns about medications. |
| Staff G | Nurse Practitioner (ARNP) | Ordered medication dose changes and provided clinical rationale; acknowledged lack of documentation for PRN use. |
Inspection Report
Follow-Up
Deficiencies: 5
Apr 5, 2014
Visit Reason
This revisit report documents the follow-up inspection to verify correction of previously cited deficiencies at Diversicare of Haysville.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions have been corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency with regulation 28-39-158(g) |
| Deficiency with regulation 28-39-158 |
| Deficiency with regulation 26-41-101(g) |
| Deficiency with regulation 26-41-202(h) |
| Deficiency with regulation 26-42-104(d) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Deficiencies: 2
Apr 5, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiencies identified in the prior survey were corrected as of the revisit date, with specific corrections noted for regulation numbers 26-40-303 (b)(c) and 26-40-305 (3).
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 26-40-303 (b)(c) |
| Deficiency related to regulation 26-40-305 (3) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Follow-Up
Deficiencies: 0
Apr 5, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies were corrected as of the revisit date, with corrections documented for multiple regulatory requirements.
Report Facts
Deficiencies corrected: 13
Inspection Report
Plan of Correction
Deficiencies: 5
Mar 12, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions to address issues related to dietary staff training, food storage, hairnet use, posting of policies, signature requirements on forms, and emergency evacuation drills.
Findings
The plan details corrective actions including mandatory staff in-services on food labeling, storage, and hairnet use, posting of residential care policies, updating and auditing of signature forms, and conducting and monitoring emergency evacuation drills to ensure compliance and resident safety.
Severity Breakdown
F: 4
D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Dietary staff not properly labeling, dating, and storing food items. | F |
| Dietary staff not properly using hairnets according to policy and Kansas Food Code. | F |
| No posting of policy and procedures in the Residential Care area. | F |
| NSA forms lacking required signatures of facility staff and resident/DPOA. | D |
| Emergency evacuation drill conducted and timed to evaluate resident safety. | F |
Report Facts
Dates for corrective actions: Mar 20, 2014
Dates for corrective actions: Apr 5, 2014
Date of emergency evacuation drill: Mar 12, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Billinger | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 6, 2014
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
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 and the plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Inspection Report
Re-Inspection
Census: 6
Deficiencies: 5
Mar 6, 2014
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with sanitary conditions, dietary services, policy availability, negotiated service agreements, and emergency preparedness.
Findings
The facility failed to store food in a sanitary manner with undated and unmarked food items, failed to ensure staff wore effective hair restraints in the kitchen, did not post availability of policies and procedures accessible to residents and families, lacked signatures on negotiated service agreements for residents, and failed to conduct an annual emergency evacuation drill.
Severity Breakdown
SS=F: 4
SS=D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to store food in a sanitary manner with undated and unmarked foods in the walk-in refrigerator, freezer, and dry storage room. | SS=F |
| Failure to ensure foods were served under sanitary conditions due to staff not wearing effective hair restraints. | SS=F |
| Failure to post availability of policies and procedures in an area accessible to residents and family. | SS=F |
| Failure to have signatures of all persons involved in the development of the Negotiated Service Agreement for sampled residents. | SS=D |
| Failure to conduct an emergency evacuation drill annually as required. | SS=F |
Report Facts
Facility census: 6
Undated thawed healthshakes: 20
Undated thawed magic cups: 13
Opened bags of pasta: 3
Residents sampled for NSA: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff J | Removed undated thawed and open food from refrigerator and freezer | |
| Registered Dietician KK | Reported staff should date and seal food items and that hairnets were required | |
| Dietary Staff N | Observed not wearing effective hair restraints in kitchen | |
| Dietary Staff O | Reminded staff N about hairnet usage | |
| Administrative Nursing Staff A | Interviewed regarding posting of policies and procedures | |
| Administrative Nursing Staff F | Interviewed regarding missing signatures on Negotiated Service Agreements | |
| Administrative Staff D | Interviewed regarding emergency evacuation drill and provided last drill documentation |
Inspection Report
Re-Inspection
Census: 102
Deficiencies: 13
Mar 6, 2014
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with regulatory requirements including dignity, comprehensive assessments, care planning, dietary services, medication administration, fall prevention, and call light system functionality.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal service, incomplete comprehensive assessments and care planning, insufficient dietary staffing causing delayed meal service, unsanitary food storage and handling practices, improper medication administration via enteral tubes, inadequate monitoring of psychoactive medication use, malfunctioning resident call light system, and ineffective Quality Assessment and Assurance program oversight.
Severity Breakdown
SS=E: 5
SS=D: 5
SS=F: 3
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to serve meals in a manner that maintained the dignity of residents sitting together at a table, with residents served at different times and inappropriate staff behavior during feeding. | SS=E |
| Failure to complete comprehensive assessments including further analysis of specific care areas for sampled residents. | SS=D |
| Failure to revise care plans after assessments to address changes such as dehydration and increased need for staff assistance. | SS=D |
| Failure to sufficiently care plan and communicate fluid restrictions for a newly admitted resident, resulting in staff not knowing or following fluid restrictions. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable well-being, specifically related to consistent adherence to fluid restrictions. | SS=D |
| Failure to ensure resident environment free of accident hazards and provide adequate supervision to prevent falls, including failure to use gait belts as planned. | SS=D |
| Failure to ensure drug regimen free from unnecessary drugs by not adequately monitoring and documenting behaviors related to psychoactive medication use. | SS=E |
| Failure to employ sufficient dietary support personnel to serve meals in a timely manner to residents. | SS=F |
| Failure to maintain sanitary food storage and handling practices, including undated/unmarked foods and staff not wearing hairnets in the kitchen. | SS=F |
| Failure to administer medications via enteral tube according to facility policy and standards of practice, including mixing medications without physician order and improper flushing. | — |
| Failure to ensure monthly pharmacist medication regimen reviews identified irregularities related to behavior monitoring for residents on psychoactive medications. | SS=E |
| Failure to ensure resident call light system functioned properly, with multiple call lights not working or broken. | SS=E |
| Failure to utilize the Quality Assessment and Assurance program effectively to identify and correct quality deficiencies in multiple areas including dignity, assessments, dietary services, medication administration, and call light system. | SS=F |
Report Facts
Facility census: 102
Residents receiving meals: 99
Fluid restriction: 1200
Fall risk assessment score: 16
Medication flush volume: 150
Meal service time range: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Q | Licensed Nurse | Administered medications via enteral tube mixing meds without physician order |
| Staff O | Dietary Staff | Reported frustration with insufficient dietary staffing and meal service delays |
| Administrative Nurse F | Administrative Nurse | Reported on QA&A program deficiencies and staffing issues |
| Physician E | Physician | Interviewed regarding medication administration practices |
| Staff M | Direct Care Staff | Reported resident behaviors related to psychoactive medication monitoring |
| Staff EE | Direct Care Staff | Reported on resident restlessness and behavior documentation |
| Staff R | Direct Care Staff | Interviewed about fluid restriction knowledge and care plans |
| Staff N | Dietary Staff | Observed not wearing hairnet properly in kitchen |
| Staff S | Direct Care Staff | Reported on resident behaviors and sleep issues |
| Staff HH | Licensed Nursing Staff | Reported lack of behavior monitoring knowledge |
| Staff II | Pharmacy Staff | Reported limited review of behavior monitoring sheets |
Inspection Report
Follow-Up
Deficiencies: 1
Jan 31, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that the previously cited deficiency with ID prefix F0309 under regulation 483.25 was corrected by 01/31/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID prefix F0309 under regulation 483.25 |
Report Facts
Deficiency correction date: Jan 31, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 31, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint survey at Diversicare Haysville.
Findings
The deficiencies involved failure to identify pain locations and time frames prior to administration of PRN pain medications for certain residents. The facility implemented staff education, updates to the EMR system, and ongoing monitoring to ensure compliance.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey at Diversicare Haysville.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to identify pain locations and time frames prior to administration of PRN pain medications for residents. | E |
Report Facts
Complete Date: Jan 31, 2014
QAPI review frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Billinger | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Jan 15, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#71437) regarding the facility's failure to properly follow physician orders and document pain assessments for residents receiving PRN pain medications.
Findings
The facility failed to follow the physician's order for administration of 'as needed' Percocet for one resident and failed to document the location of pain for three sampled residents receiving PRN pain medications. This deficiency potentially affected all 18 residents with PRN pain medication orders.
Complaint Details
Complaint investigation #71437. The facility failed to follow physician orders and properly document pain assessments, including pain location, for residents receiving PRN pain medications.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to follow physician's order for administration of 'as needed' Percocet for one resident. | SS=E |
| Failed to document the location of pain for residents receiving PRN pain medications. | SS=E |
Report Facts
Census: 95
Residents with PRN pain medications: 18
Sampled residents receiving PRN pain medications: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Interviewed regarding administration of PRN medications and documentation practices. | |
| Administrative Staff Nurse A | Interviewed regarding understanding of medication administration issues and documentation policies. |
Inspection Report
Follow-Up
Deficiencies: 1
Jun 17, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiency identified under regulation 483.65 with ID prefix F0441 was corrected as of 06/17/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.65 with ID prefix F0441 |
Report Facts
Deficiency correction date: Jun 17, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 17, 2013
Visit Reason
This plan of correction was submitted in response to deficiencies cited during a complaint survey at Diversicare Haysville.
Findings
The facility was found deficient in properly disinfecting rooms of residents with C-diff. The housekeeping department was educated on proper disinfection procedures using Clorox bleach, and a system was implemented to ensure ongoing compliance and communication between social services and housekeeping staff regarding infectious diseases.
Complaint Details
This plan of correction addresses deficiencies cited during a complaint survey.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly disinfect resident rooms with C-diff according to manufacturer recommendations. | D |
Report Facts
Complete Date: Jun 17, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elaine McDaniel | Administrator | Submitted the plan of correction |
| Shirley Boltz | Contact for plan of correction assistance |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Jun 13, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#64654) regarding infection control practices related to cleaning and disinfecting resident rooms, specifically for residents with Clostridium difficile (C-diff).
Findings
The facility failed to develop and implement a proper standard for cleaning and disinfecting rooms of residents with C-diff, including improper use of bleach solution and inadequate wet contact time, which could lead to the spread of infection.
Complaint Details
The complaint investigation found that housekeeping staff did not follow proper procedures for disinfecting rooms of residents with C-diff, including improper bleach solution use, failure to maintain required wet contact time of 5 minutes, and cross-contamination risks due to not changing gloves during cleaning.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a standard of cleaning and disinfecting resident rooms for residents with Clostridium difficile (C-diff). | SS=E |
Report Facts
Facility census: 83
Sample size: 3
Bleach to water ratio: 1
Wet time required: 5
Inspection Report
Plan of Correction
Deficiencies: 7
Dec 13, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to ensure compliance with state and federal regulations.
Findings
The facility identified multiple areas requiring correction including maintenance audits of door frames, flooring, restrooms, walls, curtains, call light cords, waste disposal procedures, care plan revisions, incontinence care, water temperature audits, inclusion of Black Box Warnings in care plans, infection control, and supervisory responsibility for dietetic services. The plan includes scheduled audits, staff in-services, competency checks, and involvement of consulting pharmacy and dietary supervisors.
Deficiencies (7)
| Description |
|---|
| Maintenance audits for door frames, flooring, restrooms, walls, curtains, call light cords, and waste disposal procedures to ensure sanitary and orderly environment. |
| Revision of residents' care plans to reflect current care needs. |
| Provision of thorough incontinence care for residents requiring assistance. |
| Repair of faulty water mixing valve and revision of water temperature audits. |
| Inclusion of Black Box Warnings (BBW) in residents' care plans for medications with such warnings. |
| Maintenance of an Infection Control Program to provide a safe, sanitary, and comfortable environment. |
| Ensuring supervisory responsibility for dietetic services by a Certified Dietary Manager. |
Report Facts
Audit frequency: 3
Audit duration: 60
Audit duration: 90
In-service date: Dec 4, 2012
Completion date: Dec 13, 2012
Dietary Supervisor assignment completion: Mar 31, 2013
Dietary Supervisor exam completion: Oct 31, 2013
Inspection Report
Re-Inspection
Deficiencies: 1
Dec 13, 2012
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Haysville Healthcare Center were corrected.
Findings
The report indicates that the deficiency identified under regulation 28-39-158(a) was corrected as of 12/13/2012.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited was corrected. |
Report Facts
Correction completion date: Dec 13, 2012
Follow-up survey completion date: Nov 14, 2012
Inspection Report
Follow-Up
Deficiencies: 7
Dec 13, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that all previously cited deficiencies were corrected as of the revisit date, with correction completion dates listed for each deficiency.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 1
Nov 14, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to ensure overall supervisory responsibility for dietetic services by a certified dietary manager, as the kitchen manager was not certified and the facility lacked a certified dietary manager for 40 hours a week. Food was prepared and served as planned, but supervisory requirements were not met.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure overall supervisory responsibility for dietetic services by a certified dietary manager. | SS=C |
Report Facts
Census: 114
Dietary staff: 4
Hours per week: 40
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 23, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint survey.
Findings
The facility identified deficiencies related to housekeeping and maintenance, including sanitary conditions and non-working equipment, and outlined corrective actions such as staff inservice, cleaning schedules, audits, and removal of defective items.
Complaint Details
This Plan of Correction is in response to deficiencies cited during a complaint survey identified as Haysville 072512 Complaint.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiencies related to housekeeping staff performance and cleaning schedules. | E |
| Deficiencies related to maintenance staff correcting items and conducting audits. | E |
Report Facts
Audit frequency: 12
Audit frequency: 3
Plan submission date: Aug 23, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elaine McDaniel | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 2
Aug 23, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that deficiencies identified under regulations 483.15(h)(2) and 483.25(h) were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 2
Jul 25, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on citations from complaint investigations #KS 56166, 57091, and 58239.
Findings
The facility failed to maintain a sanitary, orderly, and comfortable environment in 4 of 5 hallways, and failed to provide an environment free of accident hazards, including failure to provide assistive devices to prevent body entrapment for 6 residents and unsafe environmental conditions at nursing stations and the courtyard.
Complaint Details
The visit was triggered by complaint investigations #KS 56166, 57091, and 58239. The facility was found noncompliant in maintaining sanitary conditions and accident hazard prevention.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain a sanitary, orderly, and comfortable environment on 4 of 5 hallways, including dust build-up, carpet with sticky debris, missing thresholds, stained caulking, broken tiles, and unclean dining room areas. | SS=E |
| Facility failed to provide 6 residents with assistive devices (side rails) to prevent body entrapment and failed to maintain an environment free from accident hazards at nursing stations and courtyard. | SS=E |
Report Facts
Census: 114
Residents without proper assistive devices: 6
Door threshold gap: 6
Side rail opening measurements: 8
Side rail center opening measurement: 15
Rough gouged edge diameter: 2
Height of gouged edge from floor: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping/Maintenance/Laundry staff C | Reported on cleaning practices, carpet shampoo machine broken, and acknowledged cleaning deficiencies | |
| Housekeeping/Maintenance/Laundry staff B | Confirmed toilet caulking needed replacement, doorbell not working, and threshold removal | |
| Housekeeping/Maintenance/Laundry staff D | Reported on cleaning responsibilities and unawareness of some cleaning needs | |
| Administrative staff A | Confirmed carpet shampoo machine broken and discussed side rail use and maintenance responsibilities |
Inspection Report
Plan of Correction
Deficiencies: 11
N087005 POC NQC611
Visit Reason
This document is a Plan of Correction submitted by Diversicare Haysville in response to previously identified deficiencies during a regulatory inspection.
Findings
The plan outlines corrective actions to address multiple deficiencies related to resident dignity during meal service, comprehensive assessments, care plan updates, fluid restrictions, behavior monitoring, dietary staff training, medication administration, call light system maintenance, and door alarm monitoring.
Deficiencies (11)
| Description |
|---|
| Failure to ensure resident dignity during meal service including appropriate spoonful sizes and serving residents at the same time. |
| Incomplete or inaccurate comprehensive assessments for residents. |
| Care plans not updated to reflect changes in residents' conditions. |
| Staff not adequately aware of how to provide care to residents with fluid restrictions. |
| Inadequate monitoring and documentation of behaviors and psychoactive medication use. |
| Dietary staff noncompliance with job descriptions, food labeling, dating, storage, and hairnet use policies. |
| Medication administration not consistently following facility policy. |
| Call light system had non-functioning equipment requiring repair. |
| Door alarm monitoring system required upgrades and new maintenance schedule. |
| Outlet for hydroculator replaced to ensure compliance with electrical safety standards. |
| Department Heads need education on root cause analysis and follow-up of concerns. |
Report Facts
Corrective action completion dates: 2014
Number of residents reviewed: 4
Dietary meal monitoring frequency: 3
Audit frequency: 3
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