Inspection Reports for
Diversicare of Haysville

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.

Complaint Intake Numbers KS00118819 and KS00129932 were investigated in conjunction with the recertification survey.

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.

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.

This Plan of Correction is linked to a complaint investigation identified as DVC Haysville complaint 08292017.

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.

The inspection findings represent the results of complaint investigations #112451, #113607, #117668, #117798, #118209, #119131, and #119684.

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.

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.

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.

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.

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.

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.

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.

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.

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.

All previously cited deficiencies listed by regulation numbers were marked as corrected and completed as of the revisit date.

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.

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.

The visit included complaint investigations #111389, 110927, 110082, 109647, 109478, 106179, 100373, 96964, 96574, 96080, and 95475.

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.

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.

The inspection was conducted as a complaint investigation (KS00109161) focusing on resident care planning and accident prevention related to falls.

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.

This Plan of Correction is linked to a complaint investigation identified as DVC Haysville complaint 12222016.

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.

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.

Related to a complaint investigation as indicated by the reference to 'DVC Haysville complaint 07282016'.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was triggered by multiple complaint investigations (#KS00091425, #KS00090743, #KS00090572, #KS000089983) focusing on care plan revisions after falls, dietary services, and sanitary conditions.

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.

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.

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.

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.

The report documents that all previously cited deficiencies were corrected by 07/13/2014 as verified during the revisit on 08/07/2014.

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.

The survey was conducted in response to complaints #75661, #75523, #75526, and #75447.

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.

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.

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.

The report documents that the deficiency identified under regulation 483.25(l) with ID prefix F0329 was corrected as of 06/04/2014.

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.

Complaint investigation #74670 focused on the use of unnecessary antipsychotic drugs and related care practices.

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.

All previously reported deficiencies identified by regulation or Life Safety Code provisions have been corrected as of the revisit date.

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).

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.

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.

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.

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.

The report confirms that the previously cited deficiency with ID prefix F0309 under regulation 483.25 was corrected by 01/31/2014.

This Plan of Correction addresses deficiencies cited during a complaint survey at Diversicare Haysville.

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 investigation #71437. The facility failed to follow physician orders and properly document pain assessments, including pain location, for residents receiving PRN pain medications.

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.

The revisit confirmed that the deficiency identified under regulation 483.65 with ID prefix F0441 was corrected as of 06/17/2013.

This plan of correction addresses deficiencies cited during a complaint survey.

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.

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.

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.

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.

The report indicates that the deficiency identified under regulation 28-39-158(a) was corrected as of 12/13/2012.

The report shows that all previously cited deficiencies were corrected as of the revisit date, with correction completion dates listed for each deficiency.

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.

This Plan of Correction is in response to deficiencies cited during a complaint survey identified as Haysville 072512 Complaint.

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.

The report shows that deficiencies identified under regulations 483.15(h)(2) and 483.25(h) were corrected as of the revisit date.

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.

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.

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.