Inspection Reports for Diversicare of Larned
1114 W 11TH STREET, KS, 67550-1941
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 31, 2016, identified some deficiencies related to federal nursing home participation requirements, including an 'F' level deficiency indicating no actual harm but potential for more than minimal harm; these issues were addressed with a plan of correction and later verified as corrected on the same date. Earlier inspections showed a pattern of deficiencies primarily involving emergency call system functionality, care planning and assessment processes, infection control, and documentation, with several complaint investigations substantiating issues in individualized care and resident safety. Notable complaint investigations included failures in emergency call system testing frequency and individualized care planning for residents with urinary incontinence, as well as some neglect allegations related to fall prevention and reporting. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows repeated citations in similar areas but also demonstrates correction of deficiencies over time, indicating efforts toward compliance and improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
31 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
417% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
60 residents
Based on a December 2016 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 2
Dec 31, 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 revisit confirmed that the deficiencies identified under regulations 483.60(a),(b) and 483.65 were corrected as of 12/31/2016.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.65 |
Inspection Report
Re-Inspection
Deficiencies: 1
Dec 31, 2016
Visit Reason
This report documents a revisit conducted by a State surveyor to verify that previously reported deficiencies have been corrected and to record the dates when corrective actions were completed.
Findings
The revisit confirmed that the previously identified deficiency with regulation 26-40-303 (h) was corrected as of 12/31/2016. No other deficiencies or uncorrected issues were noted in this report.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-303 (h) previously reported and now corrected |
Inspection Report
Re-Inspection
Deficiencies: 1
Dec 31, 2016
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 an 'F' level deficiency, 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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Named as contact and signatory related to the survey findings and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Dec 19, 2016
Visit Reason
The inspection was conducted as a Health Survey and Complaint Investigations #8823, #7644, and #5488 to assess compliance with nursing facility regulations.
Findings
The facility failed to have a system in place to check the emergency call system functionality on a weekly basis as required, which had the potential to affect all residents. The call light in a room on the 500 hall failed to light up on the monitor panel, and the facility only conducted monthly testing instead of weekly.
Complaint Details
The inspection included complaint investigations #8823, #7644, and #5488.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have a system in place to check the emergency call system functionality on a weekly basis. | SS=F |
Report Facts
Facility census: 60
Sample size: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Maintenance staff who confirmed the call light failure and reported monthly testing. |
Inspection Report
Re-Inspection
Deficiencies: 5
Oct 7, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Diversicare of Larned were corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-201 (a)(b), 26-41-201 (c), 26-41-202 (c), 26-41-202 (e), and 26-41-204 (b) were corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-41-201 (a)(b) |
| Deficiency related to regulation 26-41-201 (c) |
| Deficiency related to regulation 26-41-202 (c) |
| Deficiency related to regulation 26-41-202 (e) |
| Deficiency related to regulation 26-41-204 (b) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 3
Sep 15, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey conducted on 2016-09-15.
Findings
The plan outlines corrective actions to ensure compliance with regulations, including implementing functional capacity screenings, negotiated service agreements, and health care service plans reviewed by licensed nurses for admissions and current residents in the assisted living apartments.
Deficiencies (3)
| Description |
|---|
| Functional capacity screening to be conducted prior to or at the time of admission, with reviews at least every 365 days. |
| Negotiated service agreement to be conducted prior to or at the time of admission, with reviews at least every 365 days. |
| Development and implementation of a health care service plan as part of the negotiated service agreement if health care services are needed. |
Report Facts
Completion date: Oct 7, 2016
Survey date: Sep 15, 2016
Review frequency: 365
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Bryan | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 6
Sep 15, 2016
Visit Reason
The inspection was conducted as a Residential Healthcare Licensure Resurvey and Complaint Investigation KS00105145 to assess compliance with functional capacity screening, reassessment, negotiated service agreements, nurse participation, and health care service planning requirements.
Findings
The facility failed to conduct functional capacity screenings on or before admission for 2 of 3 sampled residents, failed to have licensed nurses assess residents when indicated, failed to reassess a resident following a significant change in condition, failed to complete negotiated service agreements for 1 resident, failed to have licensed nurse participation in negotiated service agreements for 2 residents, and failed to develop a health care service plan for 1 resident.
Complaint Details
The visit was triggered by a complaint investigation KS00105145 focusing on compliance with functional capacity screening, reassessment, negotiated service agreements, nurse participation, and health care service planning.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to conduct functional capacity screening on or before admission for 2 of 3 sampled residents (#2 and #3). | SS=D |
| Failed to have a licensed nurse assess residents when functional capacity screening indicated need for health care services for 3 of 3 residents reviewed (#1, #2, #3). | SS=D |
| Failed to reassess a resident using the functional capacity screen following a significant change in condition for 1 of 3 residents reviewed (#2). | SS=D |
| Failed to complete a negotiated service agreement for 1 of 3 residents reviewed (#2). | SS=D |
| Failed to have a licensed nurse participate in the development of negotiated service agreements when functional capacity screening indicated need for health care services for 2 of 3 residents reviewed (#1 and #3). | SS=D |
| Failed to develop a health care service plan for 1 of 3 sampled residents (#2). | SS=D |
Report Facts
Residents in census: 5
Residents in sample: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Interviewed regarding functional capacity screening, reassessment, and negotiated service agreements |
| Therapy Staff B | Observed assisting resident #2 during functional capacity assessment | |
| Direct Care Staff C | Interviewed about care provided to resident #2 |
Inspection Report
Life Safety
Deficiencies: 1
Jun 9, 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 at the facility to be at the 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. 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 severity | F |
Report Facts
Effective date for denial of payments: Sep 9, 2016
Provider agreement termination date: Dec 9, 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 person for Informal Dispute Resolution process |
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 26, 2015
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at Diversicare of Larned.
Findings
The report documents that the previously reported deficiency identified by regulation 26-40-305 (c)(1)(2) with ID prefix S1354 was corrected as of 06/26/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency identified under regulation 26-40-305 (c)(1)(2) with ID prefix S1354 |
Report Facts
Deficiency correction date: Jun 26, 2015
Inspection Report
Follow-Up
Deficiencies: 8
Jun 26, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were corrected as of the revisit date, with corrections completed on 06/26/2015 for multiple regulatory items.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.20(b)(2)(ii) |
| Deficiency related to regulations 483.20(d), 483.20(k)(1) |
| Deficiency related to regulations 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulations 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
Inspection Report
Census: 43
Deficiencies: 1
Jun 19, 2015
Visit Reason
The inspection was a Health Licensure Resurvey conducted to assess compliance with heating, ventilation, and air conditioning system requirements.
Findings
The facility failed to ensure adequate ventilation in the beauty shop, as it lacked an exhaust vent, resulting in residents being exposed to chemical odors during beauty services.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to establish adequate ventilation in the beauty shop while residents received services, lacking an exhaust vent to the outside. | SS=E |
Report Facts
Residents present: 43
Residents receiving beauty shop services: 16
Inspection Report
Enforcement
Deficiencies: 1
Jun 19, 2015
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 an 'F' level deficiency, 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, resulting in a finding of substantial compliance effective June 26, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be an 'F' level deficiency, 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: Jun 26, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey findings |
Inspection Report
Follow-Up
Deficiencies: 3
Nov 15, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25(a)(3), and 483.25(d) were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(d) |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 4
Oct 16, 2014
Visit Reason
Complaint investigation #KS00079880 was conducted to assess compliance with care plan development, ADL care, catheter care, and urinary incontinence management.
Findings
The facility failed to develop individualized care plans based on comprehensive assessments for residents with urinary incontinence, failed to provide necessary grooming services such as shaving and hair removal, and failed to properly handle catheter care to prevent urinary tract infections. Observations and interviews confirmed standard toileting plans were used without individualization, and catheter bags were improperly placed on the floor.
Complaint Details
Complaint investigation #KS00079880 focused on care plan development, ADL care, catheter care, and urinary incontinence management. The investigation found multiple deficiencies related to individualized care planning and catheter handling.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to use results of comprehensive assessments to develop individualized care plans for urinary incontinence for residents #1, #4, and #6. | SS=D |
| Failed to provide necessary ADL care for dependent residents #4 and #6 related to grooming, including shaving and hair removal. | SS=D |
| Failed to provide catheter care to prevent urinary tract infections for resident #7; catheter bag was placed uncovered on the floor. | SS=E |
| Failed to provide individualized toileting plans to restore normal bladder function for residents #1, #4, and #6 based on 3 Day Voiding Trials. | SS=E |
Report Facts
Residents sampled: 7
Residents with urinary incontinence toileting plans reviewed: 3
Residents with catheter care reviewed: 2
Episodes of urinary incontinence: 2
Frequency of brief checks: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Confirmed lack of individualized toileting plans and improper catheter bag handling. | |
| Direct Care Staff C | Reported shaving practices and toileting routines for residents. | |
| Direct Care Staff D | Reported toileting and catheter care practices. | |
| Administrative Nurse C | Reported shaving practices for male residents. | |
| Direct Care Staff E | Assisted with catheter care observation. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Oct 16, 2014
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 an 'E' 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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was an 'E' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 3
Oct 16, 2014
Visit Reason
This Plan of Correction document responds to deficiencies cited during a complaint survey at Diversicare Larned, aiming to outline corrective actions to assure compliance with regulations.
Findings
The facility identified deficiencies related to care planning for incontinence/toileting, hygiene and shaving care, and individualized resident care plans involving use of total-lift and toileting slings. The plan includes staff training, care plan reviews, and ongoing monitoring to ensure compliance and resident care improvements.
Complaint Details
This Plan of Correction is in response to deficiencies cited during a complaint survey at the facility.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Care planning related to incontinence/toileting plan was deficient. | D |
| Hygiene and shaving care policies and practices were deficient. | D |
| Resident care involving total-lift and toileting sling use and individualized care plans was deficient. | E |
Report Facts
Deficiency completion dates: Nov 15, 2014
Training dates: Oct 29, 2014
Training dates: Oct 27, 2014
Inspection Report
Life Safety
Deficiencies: 1
Oct 7, 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 deficiency to be a 'D' level deficiency, isolated, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency, isolated, with no harm but potential for more than minimal harm that is not immediate jeopardy. | D |
Report Facts
Effective date for denial of payments: Jan 7, 2015
Provider agreement termination date: Apr 7, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 3
Apr 24, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey conducted on 2014-03-06.
Findings
The report confirms that previously identified deficiencies under regulations 28-39-158(a), 28-39-161, and 26-43-204(c) were corrected as of 2014-04-04.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) |
| Deficiency under regulation 28-39-161 |
| Deficiency under regulation 26-43-204(c) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Follow-Up
Deficiencies: 17
Apr 24, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from an earlier survey were corrected as of the revisit date.
Findings
The report documents that all previously identified deficiencies were corrected by 04/04/2014, with no uncorrected deficiencies noted at the time of the revisit.
Deficiencies (17)
| Description |
|---|
| Deficiency related to regulation 483.10(c)(2)-(5) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(g)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.25(m)(1) |
| Deficiency related to regulation 483.25(n) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b),(d),(e) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 17
Inspection Report
Follow-Up
Deficiencies: 1
Apr 24, 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 deficiency identified by regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) with ID prefix S1166 was corrected as of 04/04/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) |
Report Facts
Deficiency correction date: Apr 4, 2014
Inspection Report
Plan of Correction
Deficiencies: 19
Apr 4, 2014
Visit Reason
This Plan of Correction document is submitted in response to deficiencies cited during a prior survey to assure correction and continued compliance with state and federal regulations.
Findings
The document outlines multiple corrective actions including increased resident trust fund amounts, mandatory staff in-services on abuse reporting, dignity, skin assessment, incontinent care, medication management, infection control, and safety protocols. Responsibilities for ongoing training, monitoring, and reporting are assigned to various staff members.
Severity Breakdown
D: 13
E: 4
F: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Resident trust bag amount increased and monitored weekly. | D |
| All allegations of abuse, neglect, or exploitation will be reported and investigated thoroughly. | D |
| Observation and documentation of resident transfer to commode; staff training on dignity policy. | D |
| Mandatory training on skin assessment and reporting skin issues. | D |
| Training on incontinent resident care policy. | D |
| Training on handwashing, gloving, and peri-care skills. | D |
| Training on pressure ulcer policies and wound monitoring. | D |
| Training on toileting assistance to prevent UTIs and pressure sores. | D |
| Training on Gtube care and medication administration safety. | D |
| Training on safe handling and storage of oxygen tanks and hazardous chemicals. | E |
| Medication monitoring and behavior log development for residents on psychoactive medications. | D |
| Education on non-crushable medications and medication error reporting. | D |
| Education on influenza and pneumococcal immunizations and documentation. | E |
| Dietary staff training on glove use, sanitation, and food temperature monitoring. | E |
| Training on medication availability and documentation. | D |
| Development and monitoring of individualized behavior logs for psychoactive medication patients. | D |
| Pharmacy room/storage monitoring and staff education on medication storage and documentation. | D |
| Mandatory training on handwashing and infection control policies with ongoing observation and reporting. | F |
| Installation of red light bulbs in resident call light system to differentiate emergency lights. | E |
Report Facts
Resident trust bag amount: 50
In-service training dates: 2
Pharmacy consultant review frequency: 1
Dietary staff meal service observations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Velder | Administrator | Submitted the Plan of Correction document |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 4
Mar 26, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey, outlining corrective actions to ensure compliance with regulations.
Findings
The Plan of Correction addresses deficiencies related to glove use, food temperature monitoring, hand washing and hygiene policies, infection control protocols, and documentation of health care services summaries for residents.
Severity Breakdown
F: 3
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Improper glove usage and department sanitation standards in dietary services | F |
| Failure to properly take and record food temperatures prior to meal service | F |
| Noncompliance with hand washing and hygiene policies leading to infection control concerns | F |
| Lack of updated Health Care Services Summary documentation for residents on the Residential Care Unit | D |
Report Facts
Date of mandatory in-service training: Mar 14, 2014
Date of hand washing and hygiene in-service: Mar 26, 2014
Date housekeeping staff received in-service: Apr 4, 2014
Date Plan of Correction was submitted: Mar 26, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Velder | Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Renewal
Census: 5
Deficiencies: 3
Mar 6, 2014
Visit Reason
The inspection was conducted as a Licensure Resurvey to assess compliance with state regulations for the nursing facility.
Findings
The facility was found deficient in dietary services, infection control, and health care services. Specific issues included failure to maintain sanitary food handling and temperature monitoring, inadequate infection control practices including failure to investigate a scabies outbreak, and lack of a health care service plan for a resident requiring insulin administration.
Severity Breakdown
F: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to store, prepare, and distribute food under sanitary conditions, including improper glove use and failure to take food temperatures prior to meal service. | F |
| Failure to ensure adequate sanitation of resident rooms and failure to establish an infection control program that investigated, controlled, and prevented infections, including inadequate cleaning procedures and failure to track scabies outbreak. | F |
| Failure to have a health care service plan for a resident requiring licensed staff assistance with insulin administration. | D |
Report Facts
Census: 5
Food temperature readings: 130
Food temperature readings: 140
Food temperature readings: 150
Scabies affected residents: 4
Contact time for toilet bowl cleaner: 10
Residents sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse C | Administrative Nurse | Revealed the facility did not track or trend the scabies outbreak and described infection control measures taken. |
| Administrative staff B | Administrative Staff | Confirmed lack of Health Care Service Plan for resident #3 who required insulin injections. |
| Dietary Staff D | Dietary Staff | Confirmed gloves should be changed during meal service when contaminated and reported on food temperature log review. |
| Dietary Staff T | Dietary Staff | Observed failing to use proper sanitary procedures during food handling. |
| Dietary Staff W | Dietary Staff | Observed failing to take temperatures of foods on steam table prior to serving. |
| Housekeeping Staff BB | Housekeeping Staff | Observed cleaning toilet without allowing proper contact time for disinfectant. |
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 1
Mar 6, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations for multiple complaint numbers.
Findings
The facility failed to have an emergency call system that produced a rapidly flashing light and repeating audible signal from the room on the '500' hall. Observations showed 8 out of 8 tested call light bulbs on the 500 hallway did not differentiate between regular and emergent calls. Maintenance staff was unaware that call lights needed a differential noise or light.
Complaint Details
The visit included complaint investigations identified by complaint numbers #KS00073045, KS00071237, KS00070266, KS00069672, KS00069675, KS00069448, and KS00069418.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to have an emergency call system that produced a rapidly flashing light and repeating audible signal from the room on the '500' hall. | SS=E |
Report Facts
Census: 44
Call lights tested: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff F | Interviewed regarding call light system functionality and testing |
Inspection Report
Follow-Up
Deficiencies: 8
Dec 16, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies at Larned Healthcare Center.
Findings
The report documents that all previously cited deficiencies identified in the prior survey were corrected as of the revisit date.
Deficiencies (8)
| Description |
|---|
| Deficiency with regulation 483.10(b)(5) - (10), 483.10(b)(1) |
| Deficiency with regulation 483.15(g)(1) |
| Deficiency with regulation 483.25(f)(1) |
| Deficiency with regulation 483.25(l) |
| Deficiency with regulation 483.35(i) |
| Deficiency with regulation 483.60(c) |
| Deficiency with regulation 483.60(b), (d), (e) |
| Deficiency with regulation 483.65 |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 7
Dec 16, 2012
Visit Reason
This document is a Plan of Correction submitted by Larned HealthCare Center in response to deficiencies cited during a prior inspection, outlining corrective actions taken to address those deficiencies.
Findings
The plan details corrective actions including staff in-service education, monitoring compliance through audits and committee reviews, updating resident plans of care, and implementing tracking logs for medication and care interventions. Specific deficiencies addressed include resident rights, social services, mental health treatment, medication monitoring, dietary hair restraint compliance, insulin vial management, and oxygen tubing storage.
Severity Breakdown
D: 6
E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure residents are informed of their rights and rules governing conduct. | D |
| Failure to provide medically related social services to maintain residents' well-being. | D |
| Failure to provide appropriate treatment and services for residents with mental or psychosocial adjustment difficulties. | D |
| Failure to monitor and address adverse consequences of black box medication warnings and missing diagnoses. | D |
| Failure to ensure dietary staff wear hair restraints properly during meal preparation and serving. | E |
| Failure to properly manage insulin vial dating and disposal for diabetic residents. | D |
| Failure to provide proper oxygen tubing storage for residents using oxygen concentrators. | D |
Report Facts
Deficiencies cited: 7
In-service education dates: 3
Monitoring frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carie Perez | Administrator | Administrator submitting the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 7
Nov 21, 2012
Visit Reason
Health Resurvey inspection to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide adequate resident rights information, medically-related social services, treatment for psychosocial difficulties, monitoring of drug regimens including black box warnings, bowel management, sanitary food preparation, expired medication management, and infection control related to oxygen therapy.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide thorough information and documentation regarding Medicare residents' rights to request or decline a demand bill review upon discharge. | SS=D |
| Failure to provide medically-related social services to maintain psychosocial well-being of a resident with adjustment difficulties and antisocial behaviors. | SS=D |
| Failure to provide treatment and services for a resident displaying psychosocial adjustment difficulty. | SS=D |
| Failure to adequately monitor and assess bowel management for residents leading to prolonged periods without bowel movements and lack of follow-up. | SS=D |
| Failure to identify residents with black box warning medications on care plans and monitor for potential adverse effects. | SS=D |
| Failure to ensure drugs and biologicals were not outdated; specifically, outdated insulin was found. | SS=D |
| Failure to provide a sanitary environment to prevent infection transmission; nasal cannula and oxygen tubing improperly stored. | SS=E |
Report Facts
Resident census: 43
Sample size: 21
Residents reviewed for unnecessary medications: 10
Days without bowel movement: 5
Days without bowel movement: 4
Days without bowel movement: 6
Days without bowel movement: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Verified lack of tracking system for Medicare demand bill review notices, lack of physician notification for resident behaviors, and lack of monitoring for medication black box warnings. | |
| Nurse B | Verified outdated insulin vial found in medication storage. | |
| Dietary Staff L | Observed with hair not fully restrained during food preparation. | |
| Dietary Staff J | Verified Dietary Staff L's hair was not fully contained by hairnet. | |
| Social Service staff G | Reported resident's psychosocial issues and lack of further interventions. | |
| Physician K | Reported facility staff had not informed him of resident's behavioral issues. | |
| Aide D | Reported resident's occasional cursing and staff instructions. | |
| Aide E | Reported resident's behaviors and staff responses. | |
| Aide F | Reported resident's ongoing behaviors and documentation practices. |
Inspection Report
Follow-Up
Deficiencies: 1
Oct 18, 2012
Visit Reason
This is a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously identified deficiency with ID prefix F0514 under regulation 483.75(l)(1) was corrected as of 10/18/2012.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID prefix F0514 related to regulation 483.75(l)(1) |
Report Facts
Deficiency correction date: Oct 18, 2012
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 5, 2012
Visit Reason
This plan of correction is submitted in response to deficiencies cited related to documentation of known drug allergies in resident medical records.
Findings
The review found that known drug allergies were not always visibly documented and accurate on the Physician Order Sheets, Medication Administration Records, Treatment Administration Records, and Condition Alert Tabs for residents. The facility implemented corrective actions including chart reviews, staff in-service training, and ongoing monitoring.
Complaint Details
This plan of correction is related to a complaint investigation identified by event ID KGNO11 and deficiency report 2567.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Known drug allergies were not visibly documented and accurate on POS, MARs, TARs, and Condition Alert Tabs for residents #1, #2, and #3. | E |
Report Facts
Residents reviewed: 3
Plan completion date: Oct 12, 2012
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 3
Oct 3, 2012
Visit Reason
The inspection was an abbreviated survey conducted in response to complaint #KS00060391 regarding the facility's clinical record keeping.
Findings
The facility failed to maintain accurate and complete clinical records for 3 of 3 sampled residents, specifically lacking allergy information on September 2012 medication administration records (MARs) and physician orders. This omission was confirmed by staff interviews and observations.
Complaint Details
The visit was triggered by complaint #KS00060391 concerning incomplete and inaccurate clinical records, particularly missing allergy information on medication administration records and physician orders.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to maintain accurate and complete clinical records for resident #1, including missing allergy information on September 2012 MARs and physician orders. | SS=E |
| Failure to maintain accurate and complete clinical records for resident #2, including missing allergy information on September 2012 MARs and physician orders. | SS=E |
| Failure to maintain accurate and complete clinical records for resident #3, including missing allergy information on September 2012 MARs and physician orders. | SS=E |
Report Facts
Resident census: 44
Residents sampled: 3
Residents with MARs including allergy info: 8
Inspection Report
Follow-Up
Deficiencies: 2
Jul 17, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h) were corrected by 06/11/2012.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Jun 11, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Findings
The plan of correction addresses issues related to resident care plans, transfer needs, staff education on reportable incidents, and improvements in documentation and communication among staff. The facility outlines steps for staff counseling, in-service education, and ongoing monitoring by nursing management and the Quality Assurance committee.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as Larned Complaint 052312.
Severity Breakdown
D: 1
G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiency related to resident #1 and #2 care plans and transfer needs, including use of maxi-lift, personal alarm, and foot pedals to wheelchair. | D |
| Deficiency related to staff education and communication regarding resident transfer needs, fall monitoring, and use of assistive devices. | G |
Report Facts
Date of plan of correction completion: Jun 11, 2012
Date of scheduled in-service education call: Jun 4, 2012
Date of charge nurses in-service education: Jun 1, 2012
Date of submission: May 30, 2012
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
May 23, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of neglect involving two residents at Larned Healthcare Center.
Findings
The facility failed to immediately report three allegations of neglect involving two residents to the State Survey and Certification Agency, failed to thoroughly investigate each allegation, and failed to submit investigation results within 5 working days. Additionally, the facility failed to provide adequate supervision and assistive devices to prevent falls, resulting in fractures for both residents.
Complaint Details
The complaint investigations #KS00057293 and #KS00055144 involved allegations of neglect for Residents #1 and #2, including failure to report, investigate, and prevent falls resulting in fractures.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to immediately report allegations of neglect, thoroughly investigate, and submit results to the State Survey and Certification Agency within 5 working days for two residents. | SS=D |
| Failed to ensure residents received adequate supervision and assistive devices to prevent falls, resulting in fractures for two residents. | SS=G |
Report Facts
Census: 44
Residents selected for sample: 5
Fall risk score: 9
Fall incidents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff D | Named in the finding for failing to follow care plan and causing Resident #1's fall and fracture. | |
| Administrative Nurse B | Interviewed and confirmed details of falls and facility's failure to report and investigate neglect allegations. | |
| Direct Care Staff C | Reported leaving Resident #2 unattended on the toilet leading to a fall and fracture. |
Inspection Report
Plan of Correction
Deficiencies: 9
N073001 POC 3D5W11
Visit Reason
This document is a Plan of Correction submitted by Diversicare Of Larned in response to deficiencies cited during a prior survey, outlining corrective actions to assure compliance with state and federal regulations.
Findings
The Plan of Correction details multiple corrective actions including education of staff, review and update of care plans, behavior monitoring, medication management, housekeeping procedures, and equipment maintenance to address cited deficiencies.
Deficiencies (9)
| Description |
|---|
| Failure to complete Significant Change Status Assessment (SCSA) and update care plans for affected residents. |
| Inadequate care plan updates for residents on hospice. |
| Care plans and care cards not updated to include targeted behaviors for affected residents. |
| Lack of follow-up on gradual dose reduction recommendations and incomplete behavior documentation. |
| Failure to maintain refrigerator temperature logs in the activity department. |
| Pharmacy consultant not notified of deficiencies and lack of review of medication policies and charts. |
| Non-dated medication items not disposed of and lack of education on medication labeling and expiration. |
| Housekeeping staff not educated on chemical use and sit times; inadequate monitoring of compliance. |
| Exhaust fan installation in beauty shop completed. |
Report Facts
Completion dates: Jun 26, 2015
Affected residents: 5
Affected patients on hospice: 2
Date of exhaust fan installation: Jun 16, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Velder | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 3
N073001 POC 780T11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The facility outlines corrective actions including mandatory in-service training on medication administration, re-education of housekeeping staff on infection control, and maintenance audits on call lights to ensure compliance and prevent recurrence of deficiencies.
Deficiencies (3)
| Description |
|---|
| Mandatory in-service education on medication administration, order verification, and handling unavailable medications. |
| Re-education of staff on appropriate cleansing of resident rooms and infection control practices. |
| Maintenance audits and repairs of call lights and light panels to ensure functionality. |
Report Facts
Completion date for corrective actions: Dec 31, 2016
Frequency of audits: 3
Frequency of audits: 4
Frequency of audits: 3
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