Inspection Reports for Diversicare of Hutchinson, LLC
1202 E 23RD AVENUE, HUTCHINSON, KS, 67502-5656
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 10, 2013, included deficiencies that the facility addressed through a detailed plan of correction and a follow-up visit confirmed all cited issues were corrected. Earlier inspections identified deficiencies related to resident dignity during care, comprehensive assessments, medication management including monitoring black box warnings, and timely staff response to call lights and meal delivery. Complaint investigations in 2012 found issues with individualized toileting plans and hydration, which were addressed with corrective actions. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility showed improvement over time, resolving prior deficiencies by the most recent follow-up inspection.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
183% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
71 residents
Based on a January 2013 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Feb 10, 2013
Visit Reason
This document is a Plan of Correction submitted by Golden Plains in response to deficiencies cited in a prior inspection report, addressing corrective actions for various identified deficiencies.
Findings
The plan outlines corrective actions taken or planned for multiple deficiencies including notification forms, dignity in care, comprehensive assessments, medication management, care plan revisions, and timely response to call lights. It emphasizes staff education, systemic changes, audits, and ongoing monitoring to prevent recurrence.
Deficiencies (11)
Obtained correct notification forms from CMS; resident no longer received skilled services.
Educated staff on dignity in care, use of napkins, proper dinnerware, and timely response to resident behavior.
Systematic approach to completing comprehensive RAI assessments for all individuals cited.
Educated MDS coordinator and IDT on completing CAAs and comprehensive assessments.
Corrected residents' assessments per RAI guidelines or advanced timing for new assessments.
Reviewed and revised care plans for cited residents; daily IDT meetings to identify changes.
Physicians contacted for diagnoses; care plans and MAR updated with black box warnings; staff education on PRN medication monitoring.
Staff educated on crush medication rules; medication reviews and physician consults for medications that should not be crushed.
System changes to correct cited deficiency; staff re-educated on call light response and meal service duties.
Residents' MAR and care plans updated with black box warnings; policy review and staff education on monitoring.
All identified medications destroyed; staff re-educated on removal and destruction of outdated medications.
Report Facts
Date of corrective actions: Feb 10, 2013
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Becky Boeken | Business Office Manager | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 10
Date: Feb 10, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.
Deficiencies (10)
Deficiency identified under regulation 483.10(b)(5)-(10), 483.10(b)(1)
Deficiency identified under regulation 483.15(a)
Deficiency identified under regulation 483.20(b)(1)
Deficiency identified under regulation 483.20(g)-(j)
Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.25(l)
Deficiency identified under regulation 483.25(m)(1)
Deficiency identified under regulation 483.30(a)
Deficiency identified under regulation 483.60(c)
Deficiency identified under regulation 483.60(b), (d), (e)
Report Facts
Deficiencies corrected: 10
Inspection Report
Routine
Census: 71
Deficiencies: 9
Date: Jan 11, 2013
Visit Reason
Routine health resurvey of Golden Plains Rehabilitation Center to assess compliance with federal regulations including resident rights, dignity, comprehensive assessments, medication management, staffing, and care planning.
Findings
The facility was found deficient in multiple areas including failure to use proper Medicare Non-Coverage notice forms, undignified care practices during meals, incomplete comprehensive assessments and care area assessments (CAAs), inaccurate Minimum Data Set (MDS) assessments, failure to revise care plans after changes in resident status, failure to monitor medications with black box warnings, medication administration errors, insufficient nursing staff supervision to timely answer call lights and deliver meals, and failure to monitor expired medications.
Deficiencies (9)
Facility failed to use the proper CMS Medicare Non-Coverage notice forms for residents discharged from skilled Medicare services.
Facility failed to provide care in a dignified manner by using shirt savers to clean food and drool off a resident's face and using plastic silverware for a resident requiring assistance with eating.
Facility failed to conduct comprehensive assessments including care area assessments (CAAs) for multiple residents, missing explanations for changes in resident status and use of restraints.
Facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for residents, including cognitive and functional status.
Facility failed to review and revise care plans after changes in discharge planning and use of a geriatric chair for residents.
Facility failed to monitor black box warnings for medications, failed to include black box warnings in care plans, and failed to monitor effectiveness of as needed medications.
Facility failed to administer medications as ordered, including crushing extended release medications and administering medications at incorrect times.
Facility failed to maintain sufficient nursing staff supervision to ensure timely response to call lights and timely delivery of room trays.
Facility failed to monitor medication storage areas for expired or outdated medications affecting multiple residents.
Report Facts
Facility census: 71
Sample size: 26
Medication opportunities: 62
Medication error rate: 6.45
Residents with expired medications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Direct Care Staff | Named in medication administration errors and dignity care observations |
| Staff C | Licensed Nursing Staff | Reported on dignity care practices and medication monitoring |
| Staff H | Administrative Nurse | Reported on medication monitoring, care plan revisions, and staffing |
| Staff G | Administrative Nursing Staff | Reported on care plan completion and medication monitoring |
| Staff T | Direct Care Staff | Reported on medication monitoring and black box warnings |
| Staff M | Consultant Pharmacist | Reported on medication monitoring and black box warnings |
| Staff U | Dietary Staff | Reported on food temperature and meal delivery issues |
| Staff N | Direct Care Staff | Reported on resident care and use of geri-chair |
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 2, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that deficiencies previously cited under regulations 483.25(d) and 483.25(j) were corrected by the revisit date of 05/02/2012.
Deficiencies (2)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(j)
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: Apr 5, 2012
Visit Reason
The inspection was conducted as a complaint investigation for complaints #55089 and #55102 regarding urinary incontinence and hydration concerns.
Complaint Details
The complaint investigation FUPM11 was conducted for complaints #55089 and #55102 focusing on urinary incontinence management and hydration issues.
Findings
The facility failed to ensure residents with urinary incontinence received appropriate assessment and individualized toileting plans, and failed to provide sufficient fluids of the resident's preference to maintain proper hydration and health.
Deficiencies (2)
Failure to assess personal voiding habits and develop individualized toileting plans for residents with urinary incontinence.
Failure to consistently provide and encourage sufficient fluids of the resident's preference to maintain proper hydration and health.
Report Facts
Facility census: 64
Sample size: 15
Residents with urinary incontinence in sample: 3
Weight loss: 5
Weight loss: 10
Daily hydration requirement: 1977
Glasses of thickened fluids between meals: 3
Glasses of thickened fluids at meals: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Confirmed lack of assessment of resident's voiding patterns and failure to follow facility hydration expectations |
| Direct Care staff A | Observed assisting resident with meals and toileting | |
| Direct Care staff B | Reported frequency of resident's urinary incontinence and brief changes | |
| Direct Care staff C | Interviewed about resident's toileting assistance and meal intake | |
| Direct Care staff F | Assisted resident with toileting and meal intake, noted resident's decline | |
| Direct Care staff G | Assisted resident with toileting and meal intake | |
| Direct Care staff H | Confirmed resident's need for thickened fluids and hydration assistance | |
| Licensed Nursing staff J | Noted failure to provide thickened fluids to resident #8 |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N078003 POC FUPM11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Golden Plains Rehab.
Complaint Details
Related to a complaint investigation at Golden Plains Rehab (Complaint 040512).
Findings
The Plan of Correction indicates that no corrective action was required for the cited deficiencies F0000, F315-D, and F327-D, with completion dates in April 2012.
Deficiencies (3)
Deficiency F0000
Deficiency F315-D
Deficiency F327-D
Report Facts
Deficiency completion date: Apr 25, 2012
Deficiency completion date: Apr 5, 2012
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078003 XI6W11
Visit Reason
This document is a Plan of Correction related to a facility identified by State ID N078003 and ASPEN Event ID XI6W11.
Findings
No deficiency details or findings are provided in this Plan of Correction document; it appears to be a placeholder or empty record with no records found.
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