Inspection Reports for
Via Christi Village Hays Ks LLC

Complaint investigation #150879 focused on transfer and discharge requirements. The facility was found noncompliant in properly handling an involuntary discharge for Resident 1.

The facility failed to provide an appropriate involuntary discharge notice to a resident, did not document a valid reason for discharge, failed to obtain a physician's discharge order, and did not secure a new facility placement for the resident.

The facility acknowledges deficiencies related to transfer and discharge requirements and outlines corrective actions including education of staff and ongoing compliance monitoring through the Quality Assurance Performance Improvement Committee.

The inspection was triggered by complaints identified as #146888, #146827, and #147021.

The facility failed to provide bathing services as care planned/requested for multiple residents, placing them at risk for poor hygiene. Specific residents (R1, R5, R6, and R8) did not receive showers or baths as scheduled or requested, despite documented care plans and preferences.

The facility identified deficiencies related to activities of daily living specific to bathing for residents, including issues with care plans and bathing preferences. The plan outlines corrective actions including weekly reviews of resident no-bath lists, regular care plan reviews, and staff education to prevent recurrence.

The facility identified multiple deficiencies related to medication administration, care planning, drug regimen review, and labeling/storage of drugs. Corrective actions include revising care plans, monitoring medication administration, conducting regular audits, and ensuring appropriate diagnosis and documentation.

The facility failed to administer medications according to accepted standards for two residents, failed to meet the highest level of care for positioning for one resident, and the consultant pharmacist failed to identify and address medication irregularities including missing lab tests and inappropriate psychotropic medication use. Additionally, the facility failed to secure an expired emergency medication kit.

The report shows that multiple deficiencies previously cited were corrected by the facility, with completion dates documented as December 4, 2018.

The facility failed to provide or coordinate necessary health care services for a resident with recurring wounds on the ankles, failed to maintain evidence of criminal background checks for two certified medication aides hired in 2018, and failed to ensure complete documentation of incidents, symptoms, and actions taken related to the resident's skin condition.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 3/20/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection included a complaint investigation #121626.

The facility was found deficient in maintaining resident dignity, completing timely comprehensive assessments and care plans, preventing pressure ulcers, ensuring appropriate wheelchair positioning, managing psychotropic medications appropriately, and implementing an antibiotic stewardship program.

The plan addresses multiple deficiencies related to resident dignity, comprehensive assessments, care plan accuracy and revisions, wheelchair positioning, pressure ulcer prevention, environmental safety, appropriate diagnosis for antipsychotic medication use, and infection prevention and control including antibiotic stewardship. The facility commits to education, auditing, and ongoing monitoring to prevent recurrence.

The plan details corrective actions for multiple deficiencies related to care planning, skin assessments, hygiene, pressure ulcer prevention, range of motion, accident hazards, nutrition, medication management, staffing, food safety, and infection control. The facility commits to education, audits, and ongoing monitoring to prevent recurrence.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with bruising and hand contracture, failure to revise care plans for pressure ulcers, inadequate skin assessments and care to prevent bruising, failure to provide necessary ADL care, failure to provide physician ordered pressure ulcer prevention services, failure to prevent decrease in range of motion, environmental hazards leading to falls, failure to monitor nutritional supplement intake, duplicate antipsychotic medication therapy without proper diagnosis, a significant medication error involving antibiotic overdose, insufficient nursing staff, improper food temperature control, and inadequate infection control cleaning practices.

No deficiencies were cited in the referenced inspection report.

The survey found the most serious deficiencies to be at a 'D' level, indicating no harm with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

The revisit report confirms that the deficiency identified under regulation 483.25(c) with ID prefix F0314 was corrected as of 10/02/2015.

The plan of correction is in response to a complaint investigation survey conducted at Via Christi Village Hays.

The facility was cited for deficiencies related to prevention and treatment of pressure sores. The plan outlines corrective actions including review and revision of care plans, staff education, audits, and ongoing monitoring to ensure compliance and prevent recurrence.

The survey found a 'D' level deficiency related to pressure ulcers, indicating no actual harm but 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 October 2, 2015.

Complaint Investigation #90203. The facility failed to complete skin assessments under Resident #2's knee immobilizer to check for changes in skin integrity to prevent skin breakdown.

The facility failed to provide adequate care and treatment to prevent the development of pressure ulcers and to promote healing for one resident reviewed. Specifically, the facility did not complete skin assessments under a knee immobilizer to check for skin integrity changes, resulting in a pressure ulcer.

The revisit confirmed that the deficiency identified under regulation 483.12(a)(2) with ID prefix F0201 was corrected as of 07/29/2015.

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

Complaint investigation #89472 focused on the facility's failure to obtain proper documentation for the involuntary discharge of Resident #1, including substantiation that the resident was a danger to self or others. The resident was discharged after smoking while on oxygen, causing burns, but no physician documentation supported the discharge decision.

The facility failed to obtain required physician documentation supporting the involuntary discharge of Resident #1, who was discharged due to endangering other residents by smoking while on oxygen, resulting in burns. The medical record lacked physician statements confirming the resident was a danger to self or others.

This Plan of Correction addresses deficiencies cited in a complaint survey related to discharge documentation compliance.

The facility lacked required physician documentation for an involuntary discharge of Resident #1, which was subsequently obtained and added to the record. The plan outlines corrective actions to ensure compliance with discharge documentation requirements.

The plan outlines corrective actions for multiple deficiencies including notification of family and physicians, fall investigations, resident dignity, comprehensive assessments, care plan accuracy, pain management, pressure sore prevention, catheter care, accident prevention, nutrition status, medication management, staffing adequacy, food safety, and quality assurance processes. The facility commits to education, audits, and ongoing monitoring to ensure substantial compliance by June 12, 2015.

The survey found the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from February 16, 2015 through May 15, 2015 related to pressure ulcers (F314 CFR 01-483.25(c)). Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were recommended.

The facility had multiple deficiencies including failure to notify family and physicians of changes, inadequate care plans, failure to prevent pressure ulcers and falls, medication errors, insufficient nursing staff, and poor infection control practices.

The report confirms that the deficiencies previously cited under regulations 483.10(b)(11) and 483.25 have been corrected as of the revisit date.

This Plan of Correction is related to deficiencies cited in a complaint survey for Via Christi Village, Hays.

The facility identified deficiencies related to skin care and physician notification for residents with wounds or skin deterioration. The plan outlines corrective actions including resident discharge, physician notification protocols, staff education, and auditing procedures to ensure compliance.

The complaint investigation focused on failure to notify changes in resident conditions and failure to provide appropriate care for skin wounds and open wounds in residents #1, #2, and #3. The complaint was substantiated with findings of delayed or absent notifications to physicians and legal representatives and inadequate wound assessments and care.

The facility failed to immediately inform physicians and/or legal representatives of significant changes in residents' conditions related to skin wounds for 2 of 5 sampled residents and failed to provide necessary care and services to 2 of 3 residents with non-pressure related skin issues, including timely communication with physicians and proper wound assessments.

The facility identified multiple deficiencies related to grievance resolution, admission assessments, comprehensive assessments, care plans, pressure ulcer prevention, infection control, medication management, staffing, food safety, and environmental safety. The plan outlines corrective actions including staff education, care plan reviews, routine audits, and monitoring responsibilities with completion dates set for April 25, 2014.

The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, incomplete and inaccurate resident assessments, inadequate care planning, failure to provide necessary treatments for pressure ulcers and urinary tract infections, insufficient nursing staff to meet resident needs, improper food handling and storage, expired medications in stock, and inadequate infection control practices.

The revisit confirmed that the deficiencies previously reported under regulations 483.10(b)(11) and 483.25(c) were corrected as of 03/01/2014.

This Plan of Correction is related to deficiencies cited in a complaint investigation (Event ID OPJ711).

The plan addresses deficiencies related to communication with physicians regarding elevated temperatures and updating care plans and interventions for residents at risk of pressure ulcers. The facility outlines corrective actions including staff education, audits, and ongoing monitoring to prevent recurrence.

The citations represent findings from complaint investigations #KS00072097 and #KS00071892.

The facility failed to immediately notify the physician of a significant change in a resident's physical condition (elevated temperature) and failed to ensure residents with pressure ulcers received necessary treatment and services including consistent wound assessments and use of prescribed devices such as air boots.

The report confirms that the deficiencies previously cited under regulations 483.25(a)(3), 483.25(h), and 483.30(a) were corrected as of the revisit date.

This Plan of Correction is in response to a complaint survey identified by Event ID 29NF11 and linked to Deficiency Report (2567).

The plan addresses deficiencies related to resident bathing schedules and documentation, environmental safety including door alarms, and sufficient nursing staff to provide care. The facility outlines corrective actions including staff education, audits, and quality assurance reviews to ensure compliance.

The visit was triggered by complaint #KS68655 concerning inadequate bathing and hygiene care for residents.

The facility failed to provide adequate bathing and hygiene care to 4 sampled residents as per their care plans and preferences. Staff shortages and inadequate supervision contributed to failure in meeting residents' needs, including delayed response to call lights and door alarms. Additionally, staff failed to respond to a door alarm leading to a stairwell for over 23 minutes, posing a safety hazard.

This Plan of Correction is related to a complaint investigation survey conducted at Via Christi Village Hays.

The facility identified deficiencies related to monitoring vital signs and weights per physician orders, medication administration errors, and timely provision of laboratory services. The plan outlines corrective actions including re-education of clinical staff, clarification of physician orders, and ongoing compliance monitoring.

The complaint investigation (#KS00066524) found deficiencies related to failure to provide care and services as ordered, medication errors, and delayed laboratory services.

The facility failed to provide necessary care and services to maintain residents' highest practicable well-being, including failure to monitor vital signs and weights as ordered for residents #1 and #2. Additionally, the facility failed to ensure residents were free from significant medication errors and timely laboratory services, resulting in hospitalization of resident #1.

The revisit report shows that deficiencies identified under regulations 483.25(h) and 483.30(a) were corrected as of 04/20/2013.

The facility identified deficiencies related to accident hazards and supervision during mechanical lifts, as well as insufficient nursing staff to meet resident needs. The plan includes re-education of clinical staff and review of work schedules to ensure compliance and resident safety.

The visit was triggered by complaint investigations #KS00064457 and #KS00064469. The complaints involved inadequate supervision and assistance during mechanical lift transfers and insufficient staffing leading to delays in resident care.

The facility failed to ensure that residents' environments remained free of accident hazards due to staff not following the policy for using sit-to-stand lifts, affecting residents #6 and #7. Additionally, the facility failed to provide sufficient nursing staff to safely perform mechanical lift transfers, impacting 2 sampled residents and 15 non-sampled residents.

The report confirms that deficiencies identified in the prior survey were corrected by the dates indicated, with no uncorrected deficiencies remaining as of the revisit date.

The revisit report shows that all previously cited deficiencies were corrected as of 01/04/2013, with no uncorrected deficiencies remaining as of the revisit date.

The plan details multiple areas requiring improvement including resident care plans, investigation of un-witnessed injuries, provision of dignified services, individualized care and activity programming, infection control, medication management, staffing adequacy, food safety, and environmental safety. The facility commits to staff re-education, care plan revisions, and quality assurance monitoring to ensure compliance.

The visit was complaint-related, investigating complaint #62306. The complaint was substantiated as deficiencies were found in infection control and dietary service areas.

The facility failed to ensure daily monitoring of wash water temperatures for low temperature washing of linens and failed to maintain an air gap on six ice machine drains across six neighborhoods.

The report confirms that all previously identified deficiencies have been corrected as of the revisit date, with corrections completed on 10/07/2011 for multiple regulatory items.

The report confirms that the deficiency identified under regulation 26-40-304(d) with ID prefix Z1330 was corrected as of 10/07/2011.

The facility failed to ensure that three exit doors to the building exterior had an adequate monitoring system, with keypad codes posted and alarm delays that could allow residents to exit without triggering alarms.