Inspection Reports for
Diversicare of Hutchinson, LLC
1202 E 23RD AVENUE, HUTCHINSON, KS, 67502-5656
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
88% occupied
Based on a March 2014 inspection.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 3, 2014
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
All previously reported deficiencies were corrected by the revisit date of 06/03/2014, as documented by the correction completion dates for each cited regulation.
Report Facts
Deficiencies corrected: 16
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jun 3, 2014
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiencies previously cited under regulations 26-40-303 (h) and 26-40-303 (2)(a)(i)(ii)(iii) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-40-303 (h): Previously cited deficiency was corrected by 06/03/2014.
Regulation 26-40-303 (2)(a)(i)(ii)(iii): Previously cited deficiency was corrected by 06/03/2014.
Inspection Report
Plan of Correction
Deficiencies: 17
Date: Apr 25, 2014
Visit Reason
The document is a Plan of Correction submitted by the facility in response to survey findings, outlining corrective actions to address cited deficiencies.
Findings
The plan addresses multiple deficiencies related to resident personal funds access, privacy, care plan updates, pain management, grooming, fall prevention, medication administration, infection control, and safe storage of medications. The facility outlines education, system corrections, and monitoring plans for each deficiency.
Deficiencies (17)
F159 E: Residents #23, #67, and #5 will receive education on accessing personal funds after hours and weekends. Staff will be educated on the procedure and funds will be secured in a locked cash box with weekly audits.
F160 D: Final accounting for residents cited in the survey has been sent to Probate Jurisdiction. All residents' final accounting will be conveyed within 30 days of discharge or death with staff re-education on process and timelines.
F164 D: Hospice resident #60 was moved to a private room; staff will be re-educated on ensuring privacy during care and record access. Random audits on privacy will be conducted weekly for 90 days and quarterly thereafter.
F170 E: Staff and residents will be educated on mail delivery process on Saturdays. The Northwest Charge Nurse will deliver mail with random audits conducted.
F174 D: Resident #25's personal inventory was updated; staff will be re-educated on inventory processes and laundry distribution. Random audits will be completed weekly for 90 days and monthly thereafter.
F225 D: Investigations for resident #62's allegations will be completed. Staff will be re-educated on reporting mistreatment and misappropriation with random interviews conducted weekly for 90 days.
F248 D: Resident #60 was moved to a private room and offered one-to-one visits. Activity staff will be re-educated on developing resident activity programs with random audits conducted.
F280 E: Care plans for residents #29, #60, #22, and #5 will be updated with condition changes. Nurses and managers will be re-educated on revising care plans with random audits conducted.
F309 D: Staff education was completed to direct offering pain medication prior to resident #22's dressing change. Staff will be re-educated on pain management with random audits conducted.
F312 D: Staff will receive re-education on maintaining resident grooming and oral hygiene with random audits conducted weekly for 90 days and monthly thereafter.
F314 G: Resident #22 has pressure relieving boots and is repositioned every 2 hours. Staff will be re-educated on pressure ulcer prevention with random audits conducted.
F315 D: Resident #5 will have bladder assessment and voiding trial completed. Nursing staff will be re-educated on assessment process with audits conducted.
F323 E: Falls for residents #5 and #77 will be reviewed for causal factors. Staff will be re-educated on accident prevention and door alarm procedures with audits and inspections conducted.
F332 D: Nurses will be re-educated on administering medication via gastrostomy tube and ensuring medication label and MAR match. Random audits will be conducted.
F371 E: Staff will receive re-education on serving, preparing, and distributing food and beverages in a sanitary manner with random audits conducted.
F425 F: Staff will be re-educated on safe storage of stock medications and medication carts. Locks were changed and random audits of securing medication storage will be conducted.
F441 E: Two residents with infection control concerns had rooms deep cleaned. Staff will be re-educated on infection control principles with random audits conducted.
Report Facts
Correction Date: Apr 25, 2014
Audit frequency: 90
Audit frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Kuepker | Administrator | Named as responsible person and submitter of plan of correction |
| Becky Boeken | Named as submitter of plan of correction | |
| Don | Designee | Responsible person for multiple deficiencies |
| Maintenance Director | Responsible person for door alarm and medication storage deficiencies | |
| Social Service and Administrator | Responsible persons for personal inventory and mail delivery deficiencies | |
| Activity Director | Responsible person for activity program deficiency | |
| Business Office Manager (BOM) | Responsible for cash box reconciliation and accounting monitoring |
Inspection Report
Enforcement
Deficiencies: 1
Date: Mar 27, 2014
Visit Reason
The 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 deficiency to be a 'G' level related to pressure ulcers (F314). Due to noncompliance, a denial of payment for new Medicare admissions was imposed effective June 27, 2014, with potential termination if substantial compliance is not achieved within six months.
Deficiencies (1)
F314 Pressure Ulcers: The facility was noncompliant in preventing avoidable pressure ulcers and providing appropriate care to prevent increased complexity of existing pressure ulcers.
Report Facts
Denial of payment effective date: Jun 27, 2014
Termination recommendation date: Sep 27, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Kuepker | Administrator | Named as facility administrator in report header |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: Mar 27, 2014
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations #73540 and #70037.
Complaint Details
The visit was triggered by complaint investigations #73540 and #70037.
Findings
The facility failed to have a preventative maintenance program to check call lights weekly and failed to ensure an exterior door remained alarmed at all times, posing risks to resident safety.
Deficiencies (2)
26-40-303 (h) P E - Nursing facility support system: The facility failed to have a preventative maintenance program to test the call system weekly, resulting in call lights not functioning properly.
26-40-303 (2)(a)(i)(ii)(iii) P E - Door monitoring system: The facility failed to ensure an exterior door alarmed when opened, allowing residents to exit unsupervised.
Report Facts
Facility census: 64
Residents potentially affected: 53
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 17, 2013
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with an 'F' level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements with potential for more than minimal harm but no immediate jeopardy.
Report Facts
Effective date for denial of payments: Oct 17, 2013
Provider agreement termination date: Jan 17, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 10, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date. The report lists multiple regulation numbers with correction completion dates confirming compliance.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 10, 2013
Visit Reason
This visit was a post-certification revisit 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 or LSC provision numbers were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Feb 10, 2013
Visit Reason
This document is a Plan of Correction submitted by Golden Plains facility in response to deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions taken and systemic changes to address multiple deficiencies related to Medicare notification forms, resident dignity during care, comprehensive assessments, medication management including black box warnings, care plan revisions, and timely response to call lights and meal service.
Deficiencies (10)
F156-E: The facility obtained correct notification forms from CMS and educated staff on mandatory notices to prevent recurrence.
F241-D: Staff were educated on dignity in care, use of napkins and proper utensils, and adaptive equipment needs to maintain resident dignity.
F272-E: A systematic approach to completing comprehensive RAI assessments was implemented with coordinator education and audits.
F278-D: Residents' assessments were corrected per RAI guidelines and staff educated on documentation accuracy to prevent recurrence.
F280-D: Care plans for cited residents were revised and IDT educated on discharge planning and care plan updates.
F329-E: Physicians were contacted for medication diagnoses; care plans and MARs updated with black box warnings; staff educated on monitoring PRN medications.
F332-D: Staff educated on medication crushing rules and timing; competency evaluations scheduled to ensure compliance.
F353-E: Staff re-educated on call light response and meal service; system changes implemented to improve timely care.
F428-E: Residents' MARs and care plans updated with black box warnings; pharmacy consultant and DON review monthly to ensure compliance.
F431-D: Outdated medications were destroyed; staff re-educated on medication removal and destruction procedures.
Report Facts
Date of corrective action completion: Feb 10, 2013
Inspection Report
Routine
Census: 71
Deficiencies: 10
Date: Jan 11, 2013
Visit Reason
Routine health resurvey of Golden Plains Rehabilitation Center to assess compliance with federal regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to use proper Medicare non-coverage notice forms, failure to provide dignified care for residents requiring assistance with eating, incomplete comprehensive assessments, inaccurate MDS assessments, failure to monitor medications with black box warnings, medication errors including crushing extended-release drugs, insufficient nursing staff to timely answer call lights and deliver meals, and expired medications found in medication carts.
Deficiencies (10)
F156: Facility failed to use CMS-approved Medicare Non-Coverage notice forms for 3 residents, lacking required information and appeal instructions.
F241: Facility failed to provide dignified care for 1 resident on Special Care Unit by using shirt savers to clean food and drool and plastic silverware during meals.
F272: Facility failed to complete comprehensive assessments (CAAs) adequately for 8 residents, missing explanations for changes in condition, restraint use, psychotropic medication use, and urinary incontinence.
F278: Facility failed to review and revise care plans for 2 residents after changes in discharge planning and use of a geri-chair restraint.
F329: Facility failed to monitor black box warnings, effectiveness of PRN medications, and provide adequate indications for use for 7 residents receiving psychotropic and other high-risk medications.
F332: Facility failed to maintain medication error rate below 5% by crushing extended-release medications and administering Tylenol earlier than scheduled for 2 residents.
F332: Facility failed to administer metoclopramide before meals as ordered for 1 resident.
F353: Facility failed to maintain sufficient nursing staff to ensure timely response to call lights and timely delivery of room trays for residents on North halls.
F431: Facility failed to ensure medications for 3 residents remained in date; expired medications were found on medication carts.
F428: Consultant pharmacist failed to identify irregularity of facility's failure to monitor medications with black box warnings for 7 residents.
Report Facts
Medication error rate: 6.45
Facility census: 71
Residents on Special Care Unit: 16
Residents in sample: 26
Residents reviewed for medication errors: 10
Residents reviewed for unnecessary medications: 10
Residents with expired medications found: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Direct Care Staff | Named in medication error findings for crushing extended-release medications and early administration of Tylenol. |
| Staff C | Licensed Nursing Staff | Reported observations on use of plastic spoons and shirt savers; medication monitoring. |
| Staff H | Administrative Nurse | Reported on medication monitoring, black box warnings, and resident discharge planning. |
| Staff G | Administrative Nurse | Reported incomplete CAAs and care plan revisions. |
| Staff M | Consultant Pharmacist | Reported on medication monitoring and black box warning documentation. |
| Staff T | Direct Care Staff | Reported on medication monitoring and black box warning awareness. |
| Staff S | Licensed Nurse | Reported on medication monitoring practices. |
| Staff U | Dietary Staff | Reported on delayed meal tray delivery and cold food complaints. |
| Staff N | Direct Care Staff | Reported on use of geri-chair and resident positioning. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 2, 2012
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 confirms 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)
Regulation 483.25(d): Previously cited deficiency was corrected by 05/02/2012.
Regulation 483.25(j): Previously cited deficiency was corrected by 05/02/2012.
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 care and hydration.
Complaint Details
The complaint investigation was triggered by complaints #55089 and #55102 related to urinary incontinence care and hydration.
Findings
The facility failed to ensure residents with urinary incontinence received appropriate individualized toileting plans and assessments. Additionally, the facility failed to consistently provide and encourage sufficient fluids of the resident's preference to maintain proper hydration and health.
Deficiencies (2)
F 315: The facility failed to assess personal voiding habits and develop individualized toileting plans for 2 of 3 sampled residents with urinary incontinence, resulting in inadequate management of bladder function.
F 327: The facility failed to consistently provide and encourage sufficient fluids of the resident's preference to maintain proper hydration and health for 1 of 3 sampled residents at risk for dehydration.
Report Facts
Facility census: 64
Sample size: 15
Residents with urinary incontinence in sample: 3
Weight loss: 5
Weight loss: 10
Resident weight: 117
Daily hydration requirement: 1977
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078003 POC
Visit Reason
This document serves as a Plan of Correction related to a prior inspection event for the facility identified as State ID N078003.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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 cited in a prior complaint investigation at Golden Plains Rehab.
Findings
The plan indicates that no Plan of Correction was required for the cited deficiencies F0000, F315-D, and F327-D as of the dates listed.
Deficiencies (3)
Deficiency F0000 was cited with no Plan of Correction required as of 04/25/2012.
Deficiency F315-D was cited with no Plan of Correction required as of 04/05/2012.
Deficiency F327-D was cited with no Plan of Correction required as of 04/05/2012.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N078003 POC XI6W11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency records are found linked to this Plan of Correction document.
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