Inspection Reports for
Diversicare of Haysville

The facility failed to maintain an effective infection control program including proper use of gowns and hand hygiene during wound care for one resident, placing the resident at risk for wound infection and related complications.

The facility was found deficient in multiple areas including failure to provide dignified care, safe medication administration, appropriate resident accommodations, timely notifications of transfers, infection control, and accurate staffing data submission. Several residents were at risk due to unsafe medication practices, inadequate monitoring, and environmental hazards.

The facility was found deficient in multiple areas including failure to provide dignified care, medication management errors, inadequate resident communication accommodations, improper storage of medications and oxygen equipment, failure to monitor vital signs as ordered, incomplete transfer notifications, inconsistent weekend activities, and infection control lapses.

The complaint investigation involved allegations of theft of resident funds, failure to notify residents of trust account balances nearing SSI limits, inadequate housekeeping and maintenance, and failure to prevent sexual abuse between residents. The sexual abuse incident occurred on 09/26/23 when a resident was observed lifting another resident's dress and touching her inappropriately. Staff failed to separate them immediately, leaving the victim at risk. Immediate jeopardy was identified and removed by 09/27/23 with corrective actions including supervision, notification, and staff education.

The facility failed to safeguard resident cash resulting in theft, failed to notify residents of trust account balances nearing SSI limits, failed to maintain a sanitary and safe environment, and failed to prevent sexual abuse between residents, resulting in immediate jeopardy that was later removed.

The complaint investigation was substantiated. The resident eloped on 06/16/23, was found by a community member, and sustained injuries including abrasions and a fractured wrist. The facility was unaware of the elopement until contacted by the local fire department.

The facility failed to ensure a safe and secure environment for a high-risk resident who eloped through a door with a malfunctioning Wander Guard alarm, resulting in the resident sustaining abrasions and a fractured wrist. Corrective actions were implemented promptly, including repairs to the alarm system, staff education, and updated care plans.

The facility was found deficient in multiple areas including failure to treat residents with dignity, incomplete care plans, inadequate notification of bed hold policy, failure to prevent falls, inadequate nutritional interventions, improper oxygen therapy and equipment storage, lack of dialysis communication, insufficient monitoring of psychotropic medication side effects, failure to honor dietary preferences, unsanitary food preparation conditions, ineffective infection control related to respiratory equipment, inaccessible call lights in shower rooms, and unsafe kitchen floor conditions.

The facility had multiple deficiencies including failure to provide written bed hold policy to a resident upon hospital transfer, inadequate fall prevention interventions, failure to provide adequate nutritional interventions resulting in significant weight loss, improper oxygen therapy administration and equipment storage, lack of dialysis communication, failure to monitor side effects of psychotropic medications, failure to honor resident dietary preferences, unsanitary food preparation conditions, ineffective infection control related to respiratory equipment, inaccessible call lights in shower rooms, and unsafe kitchen floor conditions.

The facility failed to ensure a sanitary environment when Certified Nurse Aide staff did not change gloves and perform hand hygiene when moving from dirty to clean areas during two observations of incontinence care for Resident 44.

The Plan of Correction addresses multiple deficiencies including resident voting assistance, roommate notification, weight change notifications, abuse reporting, care plan updates, wound care, medication administration, food safety, sanitation, hospice coordination, and vaccination protocols. The facility has implemented education, audits, and monitoring to ensure ongoing compliance.

Complaint Intake Numbers KS00118819 and KS00129932 were investigated in conjunction with this Recertification Survey.

The facility was found not in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to assist residents in voting, failure to provide written notice of roommate changes, failure to notify physicians of significant weight loss, failure to timely report allegations of abuse, failure to notify Ombudsman of transfers, incomplete and unimplemented care plans, failure to provide necessary ADL assistance, inadequate activity programs, failure to prevent and treat pressure ulcers, inadequate supervision and assistive devices to prevent falls, incomplete nurse aide competency evaluations, incomplete nurse aide in-service training, failure to post current nurse staffing data, failure to respond to pharmacist drug regimen review recommendations, unnecessary psychotropic medication use without monitoring, medication administration errors, unsecured narcotic storage, food served at improper temperatures, unsanitary food handling, and failure to coordinate hospice services.

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 2018-09-14.

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

The plan addresses deficiencies related to resident assessments after falls, physician notification of possible injuries, fall prevention care plans, and infection control practices. The facility has implemented education, audits, and interdisciplinary reviews to ensure compliance and prevent recurrence.

The inspection was triggered by multiple complaint investigations (#112451, #113607, #117668, #117798, #118209, #119131, and #119684).

The facility failed to notify the physician of a possible injury following resident falls, failed to provide adequate supervision and interventions to prevent falls for cognitively impaired residents, and lacked an effective infection control program with real-time tracking and investigation of infection outbreaks.

This plan of correction addresses a revised complaint investigation involving allegations of verbal abuse to Resident #1. The investigation was completed and reported to KDADS. Resident #1 is no longer in the facility.

The facility investigated alleged verbal abuse involving Resident #1, who is no longer in the center. Deficiencies included failure to properly investigate and report abuse, develop and implement abuse/neglect policies, develop comprehensive care plans, and ensure laboratory orders were completed as ordered.

Complaint investigation #116615 involved allegations of staff-to-resident verbal abuse by licensed nurse staff A. The facility failed to report the allegation timely, failed to protect residents, and did not conduct a thorough investigation. The allegation was substantiated based on interviews and record review.

The facility failed to ensure staff reported an allegation of verbal abuse to administration and the State, failed to protect residents from potential abuse, and did not complete a thorough investigation. Additionally, the facility failed to develop comprehensive care plans for two residents, failed to provide ordered laboratory services for one resident, and failed to ensure physician attendance at quarterly Quality Assurance meetings.

The facility was found not to be in substantial compliance and conditions constituted immediate jeopardy to resident health or safety. Deficiencies cited included noncompliance with F225 and F226 regulations, resulting in substandard quality of care.

The plan outlines corrective actions taken or planned for multiple deficiencies including environmental issues, MDS assessment accuracy, care plan updates, pressure ulcer prevention, accident hazards, drug regimen reviews, medication record accuracy, infection control, and nursing facility support systems. Education, audits, and ongoing monitoring through the QAPI committee are described for each area.

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

The facility failed to maintain appropriate medication room temperature in one medication storage room and failed to have emergency call buttons or pull cords within resident reach in several shower and whirlpool rooms.

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

The revisit confirmed that the deficiencies identified in the prior survey were corrected by the dates indicated. All listed corrections were completed as of January 1, 2017.

This plan of correction is related to deficiencies cited during a complaint investigation at the facility.

The facility has developed and implemented a system to assure corrections and continued compliance with regulations, focusing on reviewing and revising care plans for residents who have experienced falls and reeducating nursing staff on appropriate interventions.

Complaint investigation KS00109161 focused on failure to revise care plans and implement fall prevention interventions for resident #3, who experienced multiple falls and a hip fracture.

The facility failed to revise the care plan for one resident after multiple falls and did not evaluate the effectiveness of interventions. The resident fell three times without wearing non-skid socks as required, resulting in a hip fracture. The facility also failed to maintain a sign reminding the resident to use the call light.

The survey found the most serious deficiencies to be F323, CFR 483.25(d)(1)(2)(n)(1)-(3), at a level of actual harm that is not immediate jeopardy. The facility will not be given an opportunity to correct deficiencies before remedies are imposed.

The revisit confirmed that the previously reported deficiencies, including the one under regulation 483.12(a)(7), were corrected by the date of the revisit.

The facility was found deficient in providing sufficient preparation and orientation to residents to ensure safe and orderly transfer from the facility.

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

The investigation was triggered by complaints #3390 and #2348. The complaint was substantiated as the facility did not adequately plan or implement discharge procedures for resident #1.

The facility failed to ensure staff developed and implemented discharge planning for resident #1 after issuing a 30-day discharge notice. The resident remained in the facility beyond the notice date and expressed fear and uncertainty about the discharge process. The resident was eventually transferred out of state without documented involvement of relatives or adequate discharge planning.

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

All deficiencies previously reported with regulation numbers 483.13(b), 483.13(c)(1)(i), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.13(c), 483.20(b)(1), and 483.60(b), (d), (e) were corrected as of the revisit date.

The plan addresses multiple deficiencies related to resident observation, care plan updates, abuse and neglect policies, care area assessments, and medication storage. Staff were re-educated and corrective actions were implemented to ensure compliance.

The survey found the facility was not in substantial compliance and constituted immediate jeopardy to resident health or safety from July 19, 2015 through November 6, 2015. Deficiencies cited were serious enough to warrant denial of payment for new Medicare and Medicaid admissions and potential termination of the provider agreement.

The complaint investigation #92881 involved allegations of sexual abuse by resident #4 to resident #1, including multiple incidents from July to October 2015. The facility failed to report the initial incident timely, failed to protect other residents, and failed to investigate subsequent incidents thoroughly. Additional resident-to-resident abuse involving resident #9 and resident #2 was also not 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 report confirms that the previously identified deficiency under regulation 26-43-101(g) with ID prefix S2030 was corrected as of 10/30/2015.

The plan addresses multiple deficiencies related to care plan revisions after resident falls, meal service timeliness and temperature monitoring, dietary order reviews, and sanitation of kitchen equipment. The facility outlines corrective actions, staff education, and ongoing compliance monitoring through QAPI meetings.

The inspection was triggered by multiple complaint investigations (#KS00091425, #KS00090743, #KS00090572, #KS000089983) focusing on care plan deficiencies, dietary service issues, and sanitary conditions.

The facility failed to review and revise care plans after resident falls, provide adequate supervision to prevent falls, ensure sufficient dietary staff to serve meals timely, provide therapeutic diets as prescribed, maintain food at proper temperatures, and maintain sanitary conditions in the kitchen.

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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The plan outlines corrective actions addressing multiple deficiencies including use of correct discharge forms, resident bathing preferences, individualized care plans, skin integrity monitoring, dietary service issues, medication management, and quality assurance processes.

The facility had multiple deficiencies including failure to provide correct Medicare non-coverage notices, honor resident bathing choices, provide activities meeting resident interests, develop and revise comprehensive care plans, monitor dialysis care, manage urinary incontinence, maintain nutritional status, ensure sufficient dietary staffing, maintain sanitary food handling, and properly manage medication storage and labeling. The Quality Assessment and Assurance (QAA) committee failed to effectively identify and correct quality deficiencies.

The plan addresses multiple deficiencies including grievance resolution, dignity and respect in meal service, comprehensive care plans, pressure sore treatment, special needs care, nursing staff sufficiency, food sanitation, and infection control. The facility has reviewed policies, conducted staff in-services, and implemented audits and monitoring to ensure compliance and improvement.

Complaint survey for grievances about missing personal items, dignity and respect issues, care planning deficiencies, pressure sore treatment failures, respiratory care issues, staffing shortages, food sanitation concerns, and infection control lapses.

The facility failed to promptly resolve resident grievances, provide dignified care including timely removal of room trays, develop comprehensive care plans especially for respiratory care and pressure ulcer treatment, maintain sufficient staffing to meet resident care needs, ensure sanitary food and fluid service, and implement an effective infection control program including isolation for MRSA infection.

The survey found the most serious deficiency to be a 'G' level related to pressure ulcers (F314). Enforcement remedies include denial of payment for new Medicare admissions effective September 11, 2014, until substantial compliance is achieved.

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

The report confirms that the deficiency identified under regulation 483.25(l) was corrected by the revisit date of 06/04/2014. No other deficiencies or uncorrected issues are noted.

The facility had deficiencies related to the management of antipsychotic drug regimens, including inappropriate increases in medication dosages and lack of proper documentation and review.

The complaint investigation focused on medication management, specifically the use of antipsychotic drugs and monitoring for side effects. The investigation substantiated failures in appropriate medication dosing, monitoring, and documentation.

The facility failed to ensure residents received appropriate doses of antipsychotic medications, adequate monitoring for side effects, and attempts at non-pharmacological interventions prior to medication use. There were also issues with medication order documentation and dose discrepancies.

The report documents that specific deficiencies identified in prior inspections were corrected by the revisit date.

The plan outlines corrective actions including staff in-services on food labeling, storage, and hairnet use, posting of residential care policies, updating signature requirements on forms, and conducting emergency evacuation drills to ensure compliance with federal and state regulations.

The survey found the most serious deficiencies to be widespread 'F' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective April 5, 2014.

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, failed to have signatures on negotiated service agreements for residents, and failed to conduct an annual emergency evacuation drill.

The facility had multiple deficiencies 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 call light system, and ineffective quality assurance program oversight.

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.

This plan of correction addresses deficiencies cited during a complaint investigation survey. The facility submitted corrective actions to address the complaint 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 and system updates to ensure compliance.

The revisit report confirms that the deficiency identified under regulation 483.25 with ID prefix F0309 was corrected as of the revisit date.

Complaint investigation #71437 focused on failure to follow physician orders for PRN pain medication administration and inadequate pain assessment documentation. The complaint was substantiated based on findings.

The facility failed to follow the physician's order for administration of PRN Percocet for one resident and failed to document the location of pain for three sampled residents receiving PRN pain medications. The electronic medication administration record (E-MAR) lacked a field for pain location, and nursing notes did not document pain location, which could affect all 18 residents with PRN pain medication orders.

The report confirms that the deficiency identified under regulation 483.65 with ID prefix F0441 was corrected as of the revisit date.

This plan of correction is related to a complaint investigation survey as indicated by the event and complaint IDs.

The facility was found deficient in properly disinfecting rooms of residents with C-difficile. The housekeeping staff was not fully following manufacturer recommendations for disinfecting C-diff rooms.

The findings represent the results of complaint investigation #64654 related to infection control and prevention of C-diff spread.

The facility failed to develop and implement an adequate standard for cleaning and disinfecting resident rooms of those with C-diff. Staff did not follow manufacturer recommendations for disinfecting with bleach, resulting in improper cleaning and potential spread of infection.

The facility identified multiple areas requiring corrective actions including maintenance audits for door frames, flooring, restrooms, walls, curtains, call light cords, waste disposal, care plan revisions, incontinence care, water temperature audits, inclusion of Black Box Warnings in care plans, infection control, and dietary services supervision.

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

The facility failed to ensure overall supervisory responsibility for dietetic services by a certified dietary manager. Observations and interviews confirmed the kitchen manager was not certified and the facility lacked a certified dietary manager for 40 hours a week.

The report confirms that deficiencies previously cited under regulations 483.15(h)(2) and 483.25(h) were corrected by the revisit date of 08/23/2012.

This Plan of Correction is related to deficiencies cited during a complaint survey conducted on July 25, 2012.

The facility identified deficiencies related to housekeeping and maintenance, including sanitary conditions and non-working equipment. The plan outlines corrective actions such as staff inservice, cleaning schedules, audits, and removal of defective items.

The visit was complaint-related, investigating complaints #KS 56166, 57091, and 58239.

The facility failed to maintain a sanitary, orderly, and comfortable environment on 4 of 5 hallways and failed to provide an environment free of accident hazards, including failure to provide assistive devices to 6 residents and unsafe conditions in the courtyard and nursing station.