Inspection Reports for
Diversicare of Larned
1114 W 11TH STREET, LARNED, KS, 67550-1941
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
21.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
260% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
73% occupied
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 6
Date: Jan 8, 2026
Visit Reason
The inspection was conducted to investigate complaints related to grievance handling, discharge documentation, care planning, assistance with activities of daily living, infection control practices, and facility safety.
Complaint Details
The investigation was complaint-driven, focusing on grievances about missing personal property, discharge documentation, care planning, assistance with activities of daily living, infection control, and environmental safety. The grievance related to missing clothing was found to be unresolved and undocumented.
Findings
The facility failed to document and promptly resolve a resident's grievance about missing clothing, complete discharge recapitulation for a resident, develop comprehensive care plans for residents, provide adequate assistance with personal hygiene, implement proper infection control practices including Enhanced Barrier Precautions, and maintain a safe and sanitary laundry environment.
Deficiencies (6)
F 0585: The facility failed to document and promptly resolve Resident 7's grievance regarding missing clothing items, despite awareness of the issue.
F 0628: The facility failed to complete a discharge recapitulation for Resident 47 and lacked a discharge policy.
F 0656: The facility failed to develop a comprehensive care plan for Resident 1's antipsychotic medication and Resident 31's activities of daily living.
F 0677: The facility failed to provide assistance with nail care and facial hair removal for Resident 31, despite documented needs.
F 0880: The facility failed to provide adequate infection control practices related to Enhanced Barrier Precautions, hand hygiene, and sanitizing shared equipment.
F 0921: The facility failed to maintain a safe, functional, and sanitary laundry environment, including unresolved water damage and uncovered trash.
Report Facts
Residents Affected: 44
Residents Reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Aware of missing sweaters grievance but acknowledged lack of documentation | |
| Social Services X | Provided grievance log and verified notification of missing sweaters | |
| Housekeeping/Maintenance U | Notified about missing sweaters and placed similar sweaters in resident's closet | |
| Administrative Staff D | Reported lack of discharge summary system and care plan policy | |
| Licensed Nurse I | Reported care plan development and infection control observations | |
| Administrative Nurse D | Reported expectations for care plan documentation and infection control | |
| Certified Nurse Aide N | Reported care plan usage and assistance with ADLs | |
| Certified Nurse Aide M | Reported assistance with ADLs and infection control practices | |
| Certified Nurse Aide P | Observed providing incontinent care and infection control lapses | |
| Licensed Nurse J | Observed providing catheter care with infection control lapses | |
| Maintenance Staff V | Confirmed laundry area damage and lack of repair plan |
Inspection Report
Routine
Census: 46
Deficiencies: 8
Date: Jan 17, 2024
Visit Reason
Routine inspection of Diversicare of Larned nursing home to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity/privacy, inadequate care plan revisions following falls and behavioral changes, failure to administer medications as ordered, incomplete pharmacy medication regimen reviews, unsafe wheelchair positioning, unsanitary kitchen conditions, inaccurate staffing data reporting, and ineffective infection control related to urinary catheter care.
Deficiencies (8)
F 0550: The facility failed to ensure the dignity/privacy of a resident with a urinary catheter by not covering the urine collection bag, allowing full visualization from the doorway.
F 0657: The facility failed to revise care plans timely for three residents after falls and behavioral changes, including lack of interventions for suicidal tendencies and fall prevention.
F 0684: The facility failed to administer laxatives as ordered and monitor bowel movements for a resident with constipation.
F 0689: The facility failed to ensure proper wheelchair seating and foot pedal use to prevent accidents and failed to initiate appropriate fall interventions after multiple falls resulting in fractures.
F 0756: The facility failed to follow up on pharmacy recommendations timely and failed to ensure monthly pharmacist medication regimen reviews for several residents.
F 0812: The facility failed to maintain sanitary kitchen conditions, including dirty equipment, grooved cutting boards, and dust accumulation.
F 0851: The facility failed to submit accurate and complete direct care staffing data to CMS, underreporting licensed nurse coverage on multiple days.
F 0880: The facility failed to maintain an effective infection control program by allowing a resident's urinary catheter bag to contact the floor, risking cross contamination and infection.
Report Facts
Resident census: 46
Residents sampled: 16
Pharmacy Medication Regimen Review missing months: 2
Days with inaccurate licensed nurse staffing reported: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Confirmed catheter bag infection control issue and fall intervention failures |
| Licensed Nurse I | Licensed Nurse | Confirmed catheter bag privacy and infection control issues |
| Certified Nurse Aide MM | Certified Nurse Aide | Confirmed catheter bag privacy and infection control issues |
| Administrative Staff A | Administrative Staff | Confirmed inaccurate PBJ staffing data reporting |
| Administrative Nurse E | Administrative Nurse | Confirmed medication regimen review deficiencies and fall intervention failures |
| Certified Nurse Aide P | Certified Nurse Aide | Reported resident fall risk and care concerns |
| Consulting Staff GG | Consulting Staff | Confirmed wheelchair evaluation need and medication regimen review process |
| Dietary Staff BB | Dietary Staff | Confirmed kitchen sanitation deficiencies |
Inspection Report
Routine
Census: 47
Deficiencies: 5
Date: Mar 10, 2022
Visit Reason
Routine inspection of Diversicare of Larned nursing home to assess compliance with regulatory requirements including resident notifications, bed hold policies, PASARR screening, discharge summaries, and food service sanitation.
Findings
The facility failed to notify the Ombudsman of resident hospital transfers, provide bed hold policy notifications, complete PASARR screening upon admission, document discharge summaries, and maintain sanitary food preparation practices including proper glove use and clean cooking equipment.
Deficiencies (5)
F 0623: The facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the Office of the State Long-Term Care Ombudsman for Resident 47.
F 0625: The facility failed to provide Resident 34 and Resident 47 or their representatives with the facility's bed hold policy within 24 hours after hospital admission.
F 0645: The facility failed to obtain a Care Assessment Screening (PASARR) for Resident 18 upon admission.
F 0661: The facility failed to document a discharge summary including a recapitulation of Resident 52's stay upon discharge.
F 0812: The facility failed to prepare and serve food in a sanitary manner by not changing gloves between handling ready-to-eat food items and by failing to maintain clean and properly working cooking equipment.
Report Facts
Residents census: 47
Residents sampled: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed Ombudsman notification requirements and bed hold policy issues |
| Social Service Designee C | Social Service Designee | Confirmed failure to notify Ombudsman and bed hold policy provision |
| Licensed Nurse F | Licensed Nurse | Reported not sending bed hold policy with residents discharged to hospital |
| Dietary Staff E | Dietary Staff | Observed preparing food with improper glove use and handling undercooked food |
| Dietary Staff D | Dietary Staff | Reported oven maintenance issues and planned education on food handling |
| Certified Dietary Manager D | Certified Dietary Manager | Reviewed cleaning schedules and agreed oven was dirty |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 17
Date: Dec 4, 2017
Visit Reason
Annual recertification survey and complaint investigations were conducted to assess compliance with regulatory requirements.
Complaint Details
The survey included complaint investigations related to failure to provide pain medications, inadequate posting of survey results, and medication errors.
Findings
The facility had multiple deficiencies including failure to inform Medicaid-eligible residents of chargeable services, incomplete posting of survey results, inadequate investigation and reporting of abuse allegations, incomplete abuse policy, dignity and respect issues during dining, failure to accommodate resident needs for call light use, environmental and noise issues, incomplete resident assessments, inadequate fall prevention interventions, medication administration errors, improper medication storage and handling, infection control lapses, lack of annual staff performance reviews and in-service training, and ineffective quality assurance program implementation.
Deficiencies (17)
F156: The facility failed to inform Medicaid-eligible residents of items and services that could be charged, lacking written documentation and policy.
F167: The facility failed to post and make available 3 years of survey results and plans of correction, only providing 1 year of results.
F225: The facility failed to thoroughly investigate a resident's allegation of missed pain medication and failed to report it to the state agency.
F226: The facility's abuse policy lacked investigative procedures for neglect, injuries of unknown origin, and misappropriation of property and failed to identify risk factors for abuse.
F241: The facility failed to promote dignity during dining assistance by staff eating in front of residents, standing while feeding, and using inappropriate terms.
F246: The facility failed to accommodate a resident's inability to use the call light due to cognitive impairment, lacking alternative means to notify staff.
F252: The facility failed to provide a homelike environment by frequent use of phone paging, failed to maintain ceilings in resident rooms, and allowed disruptive noise during meals.
F272: The facility failed to complete comprehensive minimum data set assessments for 4 residents, including cognition and preferences.
F323: The facility failed to determine causes and implement effective interventions for multiple falls for a resident who sustained a head injury requiring hospitalization.
F332: The facility had a medication error rate of 18.5% involving insulin administration errors, omission of medications, and administration of medications to the wrong resident.
F425: The facility failed to administer medications per physician parameters, resulting in administration of Coreg despite low blood pressure and pulse outside ordered limits.
F428: The facility's consultant pharmacist failed to identify and report medications administered outside physician prescribed parameters.
F431: The facility failed to date insulin pens when opened to ensure proper use or discard per manufacturer recommendations.
F441: The facility failed to properly disinfect multi-use glucometers between residents and failed to perform hand hygiene during medication administration.
F497: The facility failed to perform annual performance reviews for 12 direct care staff eligible for review.
F498: The facility failed to provide required annual in-service training including dementia management and abuse prevention for direct care staff.
F520: The facility failed to develop and implement an effective quality assurance program to identify issues and develop action plans to improve resident care.
Report Facts
Resident census: 55
Medication error rate: 18.5
Resident falls: 7
Insulin pen use duration: 28
Required nurse aide in-service hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff DD | Licensed Nurse | Named in medication administration and abuse allegation investigation |
| Staff F | Administrative Staff | Interviewed regarding Medicaid-eligible resident notification and abuse allegation |
| Staff B | Activity Staff | Observed eating in front of residents and assisting with meals |
| Staff M | Licensed Nurse | Observed medication administration without hand hygiene |
| Staff Z | Direct Care Staff | Administered medications to wrong resident |
| Staff K | Licensed Nurse | Observed insulin administration without priming |
| Staff L | Licensed Nurse | Observed insulin administration without priming |
| Staff A | Administrative Nurse | Interviewed about medication errors and facility policies |
| Staff C | Administrative Staff | Interviewed about QAPI program and staff reviews |
| Staff O | Social Services Staff | Interviewed about incomplete resident assessments |
| Staff I | Direct Care Staff | Interviewed about medication administration parameters |
Inspection Report
Plan of Correction
Deficiencies: 21
Date: Dec 4, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on 12/04/2017. It outlines corrective actions to address identified regulatory deficiencies.
Findings
The facility identified multiple deficiencies related to resident rights, abuse investigations, dining assistance, accommodations, environment, medication administration, infection control, and staff competency. Corrective actions include staff education, audits, policy updates, and ongoing monitoring to ensure compliance.
Deficiencies (21)
F156 – Notice of Rights, Rules, Services, Charges: Resident #37 was notified of potential charges for goods and services. Admission processes were updated to inform all residents of potential charges.
F167 – Right to Survey Results: The center made available 3 years of survey results to residents. Posting and administration processes were updated accordingly.
F225 – Investigate – Report – Allegations of Abuse: Investigation was provided regarding alleged failure to provide medication and failure to report for Resident #76. Staff educated on abuse/neglect policies and reporting.
F226 – Develop/Implement ANE policy: Abuse/Neglect/Misappropriation policy updated to include identification and investigation directions.
F241 – Dignity and Respect of individuality: Residents #17 and #39 received updated assistance with meal service. Dining process and staff education were improved.
F246 – Reasonable accommodation of needs/preferences: Resident #12 was reassessed and plan of care updated for notification accommodations. Staff educated on appropriate accommodations.
F252 – Safe/clean/comfortable/homelike environment: Staff educated on promoting a homelike environment by limiting overhead paging. Ongoing monitoring and audits implemented.
F253 – Housekeeping and Maintenance Services: Ceiling finish issues for residents #33 and #55 addressed. Environmental rounds and maintenance education ongoing.
F258 – Maintenance of Comfortable sound levels: Vacuuming during meal times addressed for residents #35 and #46. Housekeeping staff educated and audits scheduled.
F272 – Comprehensive Assessments: Minimum data set assessments for residents #18, 3, 21, and 70 updated. Staff re-educated and monitoring scheduled.
F323 – Free of accident hazards/supervision/devices: Resident #29’s care plan reviewed to ensure appropriate interventions after falls. Staff educated on post-fall assessments.
F332 – Free of medication Error rates of 5% or more: Medication administration for residents #8, 61, 56, and 55 reviewed and found appropriate. Staff educated and audits planned.
F371 – Food Procure, store/prepare/serve-sanitary: Undated food items removed. Staff re-educated on food handling and sanitation. Audits scheduled.
F425 – Pharmaceutical SVC-Accurate Procedures, RPH: Resident #68 medication administered per physician orders. Staff educated and medication records reviewed weekly.
F428 – Drug regimen review: Resident #68’s medication plan reviewed. Consultant pharmacist education and monthly reviews scheduled.
F431 – Drug Records, Label/Store Drugs & Biologicals: Medication carts checked for dated insulin pens and proper disposal. Staff educated and audits scheduled.
F441 – Infection Control, Prevent Spread, Linens: Staff re-educated on glucometer cleansing and hand hygiene during medication administration. Audits scheduled.
F497 – Nurse Aide perform review 12 hours / year in-service: Twelve direct care team members completed competency evaluations within 12 months. Ongoing audits planned.
F498 – Nurse Aide Demonstrate competency/care needs: Direct care team members completed 12 hours of in-service including dementia care management. Monthly audits planned.
F520 – QAA Committee Plans: QAPI committee reviewed and approved plans to correct deficiencies. Interdisciplinary team re-educated on QAPI process with ongoing reviews.
S1174 – Door monitoring system: Door monitoring system serviced and found working correctly with new annunciator installed. Weekly checks and QAPI reviews scheduled.
Report Facts
Direct care team members: 12
Residents referenced in deficiencies: 15
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 31, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies were corrected by the facility as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 31, 2016
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies.
Findings
The report confirms that previously reported deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-303 (h) deficiency was corrected and completed by 12/31/2016.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 31, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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 the credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 31, 2016
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report documents that previously identified deficiencies have been corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 31, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Dec 19, 2016
Visit Reason
The inspection was conducted as a Health Survey and Complaint Investigation related to the facility's emergency call system functionality and maintenance.
Complaint Details
The visit included complaint investigations #8823, #7644, and #5488. The facility failed to provide a policy regarding call light maintenance as requested on 12/12/16.
Findings
The facility failed to have a system in place to check the emergency call system functionality on a weekly basis as required, conducting only monthly testing. This deficiency had the potential to affect all residents.
Deficiencies (1)
26-40-303 (h) P E - Nursing facility support system: The facility failed to test the emergency call system weekly, performing only monthly checks, which could affect all residents.
Report Facts
Facility census: 60
Sample size: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff C confirmed the call light failure and reported monthly testing of call lights |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 7, 2016
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at Diversicare of Larned.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: 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 inspection.
Findings
The facility has developed and will implement policies for functional capacity screening and negotiated service agreements for admissions to the assisted living apartments. Licensed nurses will review and assess residents' health care needs at admission, with significant changes, and annually to ensure compliance.
Deficiencies (5)
S3080 The facility lacked a consistent policy for conducting functional capacity screenings at admission, significant change, and annually. Licensed nurses will now review and assess residents' health care needs accordingly.
S3081 The facility lacked a consistent policy for conducting functional capacity screenings at admission, significant change, and annually. Licensed nurses will now review and assess residents' health care needs accordingly.
S3090 The facility lacked a consistent policy for conducting negotiated service agreements at admission, significant change, and annually. Licensed nurses will now review and assess residents' health care needs accordingly.
S3091 The facility lacked a consistent policy for conducting negotiated service agreements at admission, significant change, and annually. Licensed nurses will now review and assess residents' health care needs accordingly.
S3156 The facility lacked a policy for developing and implementing health care service plans as part of negotiated service agreements when health care services are needed. Licensed nurses will now develop, review, and assess these plans accordingly.
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 6
Date: Sep 15, 2016
Visit Reason
The inspection was conducted as a Residential Healthcare Licensure Resurvey and Complaint Investigation KS00105145 at Diversicare of Larned.
Complaint Details
The inspection included a complaint investigation identified as KS00105145.
Findings
The facility failed to conduct functional capacity screenings on or before admission for 2 of 3 sampled residents and failed to have a licensed nurse assess residents when the screening indicated the need for health care services. The facility also failed to reassess a resident following a significant change in condition, complete negotiated service agreements at admission, ensure licensed nurse participation in service agreement development, and develop a health care service plan for one resident.
Deficiencies (6)
KAR 26-41-201(a) The facility failed to conduct a functional capacity screening on or before admission for 2 of 3 sampled residents.
KAR 26-41-201(b)(2) The facility failed to have a licensed nurse assess residents when the functional capacity screening indicated the need for health care services for 3 of 3 residents reviewed.
KAR 26-41-201(c)(2) The facility failed to reassess a resident using the functional capacity screen following a significant change in condition for 1 of 3 residents reviewed.
KAR 26-41-202(c) The facility failed to complete a negotiated service agreement at admission for 1 of 3 residents reviewed.
KAR 26-41-202(e) The facility failed to have a licensed nurse participate in the development of negotiated service agreements when the functional capacity screen indicated the need for health care services for 2 of 3 residents reviewed.
KAR 26-41-204(b) The facility failed to develop a health care service plan for 1 of 3 sampled residents whose functional capacity screening indicated the need for health care services.
Report Facts
Facility census: 5
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Interviewed regarding functional capacity screenings, assessments, and facility policies. |
| Direct Care Staff C | Direct Care Staff | Interviewed regarding resident care and observations. |
| Therapy Staff B | Therapy Staff | Observed assisting resident during functional capacity assessment. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 9, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an "F" level, indicating no harm but with 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.
Report Facts
Effective date for denial of payments: Sep 9, 2016
Effective date for provider agreement termination: Dec 9, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement actions. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 9, 2016
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 deficiencies at an 'F' level, indicating no harm but with 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.
Report Facts
Effective date for denial of payments: Sep 9, 2016
Effective date for provider agreement termination: Dec 9, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in enforcement context. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jun 26, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey. It outlines corrective actions to ensure compliance with state and federal regulations.
Findings
The facility identified multiple deficiencies related to care plan updates, medication management, behavior documentation, hospice care, housekeeping, and medication labeling. The Plan of Correction details steps to address these issues through education, process changes, and monitoring.
Deficiencies (9)
F274-D MDS will complete significant change assessments for affected residents and update care plans accordingly. Education on care plan changes will be provided to the treatment team.
F279-D Treatment team will review and update care for hospice patients and educate staff on hospice services and care plan updates. Care plan meetings will include resident/family and hospice.
F280-E Care plans and care cards for affected residents will be reviewed and updated to include targeted behaviors. Monthly reviews of behavior books will ensure current information.
F329-E Psychiatrist consulted on gradual dose reduction for a resident. Education will be provided on follow-up procedures and behavior documentation for psychoactive medication use.
F371-E Activity Director will maintain refrigerator temperature logs and educate staff to ensure compliance with temperature monitoring standards.
F428-E DON will notify pharmacy consultant of deficiencies and review medication policies. Pharmacy consultant will conduct monthly reviews and report findings to QA.
F431-D Non-dated medication items were disposed. Education on medication labeling and dating will be provided to nursing staff and CMA's. Ongoing medication cart reviews will continue.
F441-F Housekeeping staff will receive education on chemical use per manufacturer recommendations. Ongoing education and monitoring will be conducted to ensure compliance.
S1354-E An exhaust fan was installed in the beauty shop to meet environmental standards.
Report Facts
Affected residents for care plan updates: 5
Patients on hospice: 2
Plan of Correction completion dates: Jun 26, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Velder | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 26, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency identified by regulation 26-40-305 (c)(1)(2) with ID prefix S1354 was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2) deficiency previously cited was corrected by 06/26/2015.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 26, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 26, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Diversicare of Larned.
Findings
The report confirms that the previously cited deficiency under regulation 26-40-305 (c)(1)(2) with ID prefix S1354 was corrected as of 06/26/2015.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 26, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that all previously reported deficiencies were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 19, 2015
Visit Reason
A Health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
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 the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the plan of correction acceptance. |
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 1
Date: Jun 19, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to evaluate compliance with heating, ventilation, and air conditioning regulations.
Findings
The facility failed to ensure adequate ventilation in the beauty shop, lacking an exhaust vent which caused chemical odors to affect residents receiving services there.
Deficiencies (1)
KAR 26-40-305 (c)(2) Heating, ventilation, and air conditioning systems were not adequately ventilated in the beauty shop. The facility lacked an exhaust vent, exposing residents to chemical odors during services.
Report Facts
Facility census: 43
Residents receiving beauty shop services: 16
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 19, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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 the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that was not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter regarding the plan of correction and compliance status. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Nov 15, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that deficiencies previously cited under regulations 483.20(d), 483.20(k)(1), 483.25(a)(3), and 483.25(d) were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.20(d), 483.20(k)(1): Previously cited deficiencies were corrected by 11/15/2014.
Regulation 483.25(a)(3): Previously cited deficiency was corrected by 11/15/2014.
Regulation 483.25(d): Previously cited deficiency was corrected by 11/15/2014.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 15, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint survey.
Findings
The facility identified deficiencies related to care planning for urinary incontinence and toileting, hygiene and grooming practices, and individualized resident care plans involving use of total-lift and toileting slings. The Plan of Correction outlines staff training, care plan revisions, and ongoing monitoring to address these issues.
Deficiencies (3)
F279-D: Care planning related to incontinence/toileting was deficient. Residents #1, 4, and 6 required bladder diaries and individualized urinary incontinence/toileting plans.
F312-D: Hygiene and grooming practices were deficient. Mandatory staff training and skills check-offs on shaving and grooming were implemented to improve care.
F315-E: Resident care involving use of total-lift and toileting sling was deficient. Individualized care plans and bladder diaries were developed for residents using these devices.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Date: Oct 16, 2014
Visit Reason
Complaint investigation #KS00079880 was conducted to assess the facility's compliance with care plan development, ADL care, catheter care, and urinary incontinence management.
Complaint Details
The deficiencies represent findings from complaint investigation #KS00079880.
Findings
The facility failed to develop individualized care plans based on comprehensive assessments for residents with urinary incontinence. It also failed to provide necessary ADL care related to grooming and hygiene, and did not handle catheter care properly to prevent urinary tract infections.
Deficiencies (3)
F279: The facility failed to use comprehensive assessment results to develop individualized toileting care plans for residents #1, #4, and #6.
F312: The facility failed to provide necessary grooming and personal hygiene services to residents #4 and #6, including daily shaving and hair removal.
F315: The facility failed to provide appropriate catheter care to resident #7 and failed to develop individualized toileting plans to restore bladder function for residents #1, #4, and #6.
Report Facts
Census: 48
Residents sampled: 7
Residents reviewed for ADLs: 4
Residents reviewed for catheter care: 2
Residents reviewed for urinary incontinence/toileting plans: 3
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 7, 2014
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 a 'D' level deficiency, isolated, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited with a 'D' level deficiency related to Life Safety Code compliance, indicating isolated noncompliance with potential for more than minimal harm but no immediate jeopardy.
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 enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 24, 2014
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously identified deficiencies under regulations 28-39-158(a), 28-39-161, and 26-43-204(c) were corrected as of 04/04/2014.
Deficiencies (3)
Regulation 28-39-158(a) deficiency was corrected by 04/04/2014.
Regulation 28-39-161 deficiency was corrected by 04/04/2014.
Regulation 26-43-204(c) deficiency was corrected by 04/04/2014.
Inspection Report
Follow-Up
Deficiencies: 17
Date: Apr 24, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that all previously cited deficiencies were corrected by the facility as of 04/04/2014.
Deficiencies (17)
Regulation 483.10(c)(2)-(5): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.15(a): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25: Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25(a)(3): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25(c): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25(d): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25(g)(2): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25(h): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25(l): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25(m)(1): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.25(n): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.35(i): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.60(a),(b): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.60(c): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.60(b),(d),(e): Previously cited deficiency corrected as of 04/04/2014.
Regulation 483.65: Previously cited deficiency corrected as of 04/04/2014.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 24, 2014
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency with regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of 04/04/2014.
Deficiencies (1)
Regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) deficiency was corrected on 04/04/2014.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 24, 2014
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at Diversicare of Larned.
Findings
The report documents that the previously cited deficiency under regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of 04/04/2014.
Deficiencies (1)
Regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) deficiency was corrected on 04/04/2014.
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Apr 4, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey. It outlines corrective actions to address the cited deficiencies and ensure ongoing compliance with state and federal regulations.
Findings
The plan details multiple corrective actions including increased resident trust fund amounts, mandatory staff in-service trainings on abuse reporting, dignity, skin assessment, incontinent care, wound care, medication management, infection control, and safe oxygen handling. Responsibilities for ongoing monitoring and reporting are assigned to various staff members.
Deficiencies (18)
F159-D: The resident trust bag amount will be increased from $10 to $50 and monitored weekly to better serve residents on evenings and weekends.
F225-D: All allegations of abuse, neglect, or exploitation will be reported to KDADS with thorough investigations and mandatory staff training on abuse policies.
F241-D: PT, OT, and DON will observe and document resident transfers; mandatory staff training on dignity policy will be conducted monthly and ongoing.
F309-D: Mandatory training for CNAs and nurses on skin assessment and reporting; monthly review of skin assessments by DON.
F312-D: Mandatory training on incontinent resident care policy with ongoing monitoring and reporting.
F314-D: Training on pressure ulcer prevention, wound monitoring, and documentation with ongoing staff education and reporting.
F315-D: Training on incontinent care and toileting assistance to prevent UTIs and pressure sores with ongoing monitoring.
F322-D: Training nurses on Gtube care including auscultation and aspiration, with ongoing education and monitoring.
F323-E: Staff training on safe oxygen tank handling and storage; maintenance supervisor to monitor compliance and report monthly.
F329-D: Medication review and monitoring for residents on psychoactive drugs with behavior logs and mandatory nurse training.
F332-D: Education on non-crushable medications for CMA's and medication error reporting by DON.
F334-E: Education on influenza and pneumococcal immunizations with documentation and monitoring by Infection Control Nurse and MDS nurse.
F371-E: Dietary staff training on glove use, food handling, and temperature monitoring with ongoing observation and reporting.
F425-D: Training nurses on medication availability and documentation with ongoing monitoring by DON.
F428-D: Development and monitoring of individualized behavior logs for patients on psychoactive medications with monthly pharmacy consultant review.
F431-D: Pharmacy room and medication storage monitoring with staff education on temperature protocols and medication storage.
F441-F: Mandatory training on handwashing and hygiene with skill checks and infection control monitoring by DON and ADON.
S1166-E: Installation of red light bulbs in resident call light system to differentiate emergency lights with maintenance monitoring.
Report Facts
Resident trust bag amount: 50
Mandatory in-service dates: 2
Training observation period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Velder | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Mar 26, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey to assure correction and continued compliance with regulations.
Findings
The Plan of Correction addresses deficiencies related to glove use, food temperature monitoring, hand washing and hygiene, infection control protocols, and documentation of health care services summaries for residents.
Deficiencies (5)
Glove use was found noncompliant; a mandatory in-service was held to reeducate dietary staff on proper glove usage and sanitation standards. New hires will receive training and meal services will be observed to ensure compliance.
Food temperature monitoring was deficient; dietary staff received training on taking temperatures of all food items prior to meal service and policies were reviewed. Temperature logs will be monitored for compliance.
Hand washing and hygiene practices were inadequate; mandatory in-service was held to educate staff on infection prevention and cross contamination. DON and ADON will observe and ensure ongoing compliance.
Housekeeping staff were trained on proper disinfectant contact time for cleaning toilets to meet manufacturer recommendations. Infection control program compliance will be monitored regularly by DON and ADON.
All residents on the Residential Care Unit must have a Health Care Services Summary updated at least annually or with condition changes. Responsibility assigned to Healthcare Information Specialist under facility administrator supervision.
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 1
Date: Mar 6, 2014
Visit Reason
The visit was a health resurvey and complaint investigations related to multiple complaint case numbers.
Complaint Details
The inspection included complaint investigations with case numbers KS00073045, KS00071237, KS00070266, KS00069672, KS00069675, KS00069448, and KS00069418.
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 that 8 out of 8 tested call light bulbs on the 500 hallway did not differentiate between regular and emergent calls.
Deficiencies (1)
26-40-303 (b)(i)(ii)(iii)(iv)(c) P E - Nursing facility support system. The facility failed to have an emergency call system that produced a differentiating sound or bulb to show an emergent call light on hall '500'.
Report Facts
Census: 44
Call lights tested: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance staff F | Reported monthly testing of call lights and denied awareness of need for differential noise or light. |
Inspection Report
Renewal
Census: 5
Deficiencies: 3
Date: Mar 6, 2014
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with state regulations for the nursing facility.
Findings
The facility failed to maintain sanitary food handling and preparation practices, ensure proper infection control including investigation of a scabies outbreak, and lacked a health care service plan for a resident requiring licensed staff assistance with insulin administration.
Deficiencies (3)
28-39-158(a) Dietary Services: The facility failed to store, prepare, and serve food under sanitary conditions, including failure to change contaminated gloves and take food temperatures prior to meal service.
28-39-161 Infection Control: The facility failed to ensure adequate sanitation of resident rooms and did not establish an infection control program that investigated and prevented infections, including a scabies outbreak.
26-43-204(c) Health Care Services: The facility failed to have a health care service plan for a resident who required licensed staff assistance with insulin administration.
Report Facts
Resident census: 5
Residents affected by scabies: 4
Residents selected for sample: 3
Inspection Report
Plan of Correction
Deficiencies: 8
Date: 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. It outlines corrective actions taken to address identified issues.
Findings
The plan addresses multiple deficiencies related to resident rights, social services, mental health treatment, medication monitoring including black box warnings, dietary staff hygiene, insulin vial management, and oxygen concentrator storage. The facility describes education, monitoring, and compliance measures implemented to correct these issues.
Deficiencies (8)
F156-D: The facility must ensure all residents are informed of their rights orally and in writing in a language they understand. A system to document Medicare residents' requests or declines for demand bill review upon discharge will be implemented.
F250-D: The facility must provide medically related social services to maintain residents' well-being. Resident #54 is receiving psychiatric consultation and one-on-one visits to assist with adjustment difficulties.
F319-D: Residents with mental or psychosocial adjustment difficulties must receive appropriate treatment. Resident #54 is being treated per physician orders with weekly reviews.
F329-D: Plans of care must include monitoring for adverse consequences of black box warnings for specified residents. Education and audits on medication monitoring are conducted regularly.
F371-E: Dietary staff must wear hair restraints effectively during meal preparation and serving. Staff received education and compliance is monitored through documented rounds.
F428-D: Plans of care must reflect monitoring for black box warnings and bowel assessments. Orders and assessments were updated for specified residents.
F431-D: Insulin vials must be dated legibly with open and discard dates. An insulin vial was disposed of due to being outdated. Compliance is monitored weekly.
F441-D: Oxygen concentrators must have plastic bags affixed for tubing storage when not in use. Charge nurses will check and document presence during shift rounds.
Report Facts
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carie Perez | Administrator | Administrator submitting the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 16, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 12/16/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 16, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 8
Date: Nov 21, 2012
Visit Reason
Health resurvey inspection to evaluate compliance with previously cited deficiencies and overall 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.
Deficiencies (8)
F156: The facility failed to provide thorough information and follow-up regarding Medicare residents' rights to request or decline a demand bill review upon discharge for 1 of 3 sampled residents.
F250: The facility failed to provide medically related social services to maintain psychosocial well-being for a resident with adjustment difficulties and antisocial behaviors.
F319: The facility failed to provide treatment and services for a resident displaying psychosocial adjustment difficulty, including monitoring and physician notification of behavioral issues.
F329: The facility failed to ensure residents' drug regimens were free from unnecessary drugs and failed to monitor and care plan for black box warning medications for multiple residents.
F371: The facility failed to ensure thorough hairnet coverage during food preparation, risking contamination.
F428: The facility's pharmacist failed to report irregularities in medication regimens, including inadequate bowel management and lack of monitoring for black box warnings for multiple residents.
F431: The facility failed to ensure expired insulin was discarded and monitored properly for an insulin-dependent diabetic resident.
F441: The facility failed to maintain sanitary conditions to prevent infection transmission related to improper storage of nasal cannula and oxygen tubing for residents receiving oxygen therapy.
Report Facts
Resident census: 43
Residents sampled: 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
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 18, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the Plan of Correction.
Findings
The report confirms that the deficiency identified under regulation 483.75(l)(1) with ID prefix F0514 was corrected by the revisit date of 10/18/2012.
Deficiencies (1)
Regulation 483.75(l)(1) deficiency identified by prefix F0514 was corrected as of 10/18/2012.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 18, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the prior survey conducted on 2012-10-03.
Findings
The report confirms that the previously cited deficiency with regulation number 483.75(l)(1) was corrected as of 2012-10-18. No other deficiencies are listed.
Deficiencies (1)
Regulation 483.75(l)(1) deficiency was corrected by the revisit date of 2012-10-18.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 5, 2012
Visit Reason
This document is a plan of correction submitted in response to deficiencies cited during a complaint investigation.
Complaint Details
This plan of correction is related to a complaint investigation identified as Larned 100312 Complaint.
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 #1, #2, and #3.
Deficiencies (1)
F514-E: The Physician Order Sheets, Medication Administration Records, Treatment Administration Records, and Condition Alert Tabs were reviewed and found to lack timely and accurate documentation of known drug allergies for residents #1, #2, and #3.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 3
Date: Oct 3, 2012
Visit Reason
The inspection was an abbreviated survey conducted in response to complaint #KS00060391 regarding clinical record accuracy and completeness.
Complaint Details
The complaint investigation was triggered by complaint #KS00060391 concerning incomplete and inaccurate clinical records, specifically missing allergy information on medication administration records and physician orders.
Findings
The facility failed to maintain accurate and complete clinical records for 3 of 3 sampled residents. Specifically, allergy information was missing or inconsistent on September 2012 medication administration records (MARs) and physician orders for residents #1, #2, and #3.
Deficiencies (3)
483.75(l)(1) The facility failed to maintain accurate and complete clinical records for resident #1 when September 2012 MARs and physician orders lacked allergy information, leading to confusion during an emergency.
483.75(l)(1) The facility failed to maintain accurate and complete clinical records for resident #2 when September 2012 MARs and physician orders lacked allergy information.
483.75(l)(1) The facility failed to maintain accurate and complete clinical records for resident #3 when September 2012 MARs and physician orders lacked allergy information.
Report Facts
Resident census: 44
Residents sampled: 3
Residents with MAR allergy info: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 1, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 17, 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 revisit confirmed that the deficiencies related to regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h) were corrected by 06/11/2012.
Deficiencies (2)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiencies were corrected by 06/11/2012.
Regulation 483.25(h): Previously cited deficiency was corrected by 06/11/2012.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: 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.
Complaint Details
This plan of correction is related to a complaint investigation identified as Larned Complaint 052312.
Findings
The plan of correction addresses issues related to resident care plans, transfer needs, staff education on reportable incidents, and communication of resident mobility and fall risk precautions.
Deficiencies (2)
F225-D: The employee was counseled and educated regarding resident #1 plan of care and transfer needs. Resident #2's plan of care was updated to include maxi-lift, personal alarm, stay with me during toileting, and foot pedals to wheelchair.
F323-G: Residents mobilizing independently in wheelchairs receiving staff assist have been reassessed for assistive devices and foot pedals applied as needed. Staff received in-service education on resident transfer needs, fall prevention, and nurse aide information sheets.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: May 23, 2012
Visit Reason
Complaint investigations were conducted regarding allegations of neglect involving two residents at the facility.
Complaint Details
The investigation was triggered by complaints regarding neglect of residents #1 and #2. The allegations were not substantiated by the facility's reporting, investigation, or corrective actions as required by state regulations.
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 two residents.
Deficiencies (2)
F225: The facility failed to report allegations of neglect involving two residents, failed to thoroughly investigate these allegations, and did not submit investigation results to the State Survey and Certification Agency within 5 working days.
F323: The facility failed to ensure two residents received adequate supervision and assistive devices to prevent falls, resulting in fractures. Staff did not follow care plans for transfers and failed to use foot pedals on a wheelchair, causing a resident to fall.
Report Facts
Resident census: 44
Residents sampled: 5
Fall incidents: 3
Fall risk score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff D | Named in findings for failing to follow care plan during transfer of resident #1, resulting in a fall and fracture. | |
| Administrative Nurse B | Interviewed regarding incidents and facility's failure to report and investigate neglect allegations. | |
| Direct Care Staff C | Reported leaving resident #2 unattended on the toilet, contributing to a fall and fracture. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: 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 to assure corrections and continued compliance with regulations.
Findings
The plan 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 address cited deficiencies.
Deficiencies (3)
F425-D There will be mandatory in-service education on medication administration rights, order verification, and handling unavailable medications. The Director of Nursing will perform medication audits and ongoing staff training.
F441-E Staff member A was reeducated on proper room cleansing and wet times to prevent infection spread. Housekeeping staff will receive re-education and audits on cleaning and infection control techniques.
S1172-F The maintenance supervisor will audit all call lights, repair non-functional units, and maintain logs reviewed at Quality Assurance meetings to ensure compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N073001 POC
Visit Reason
This document is a plan of correction related to a previously identified deficiency report for the facility.
Findings
No deficiency records or findings are included in this plan of correction document.
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