Inspection Reports for
Via Christi Village Hays Ks LLC

The facility had multiple deficiencies including failure to provide dignified dining for a resident requiring assistance, failure to implement gradual dose reduction for psychotropic medication, failure to provide required bed hold notifications, incomplete care plans for residents on oxygen and with immobilizers, skin breakdown and foot care issues, improper resident transfers causing injury, significant weight loss without adequate intervention, improper storage of respiratory equipment, failure to hold blood pressure medication per orders, expired and unlabeled medications, inadequate dental services, lack of certified dietary manager, unsanitary kitchen conditions, incomplete staff training, and failure to implement infection control precautions.

The complaint was substantiated as the facility failed to follow Resident 1's care plan preferences, leading to impaired dignity.

The facility failed to provide care according to Resident 1's preferences, resulting in the resident being exposed in the dining room without a bra, which placed the resident at risk for impaired dignity. Observations, record reviews, and interviews confirmed the deficiency.

The facility failed to ensure dignity and privacy for residents, prevent medication errors, employ a full-time certified dietary manager, and serve palatable food at proper temperatures. Several residents were observed without privacy catheter bags, medication errors occurred including crushing medications that should not be crushed and missed doses, and food quality and temperature issues were noted.

The facility had multiple deficiencies including failure to maintain resident dignity, incomplete assessments, inadequate care planning especially for dementia and anticoagulant use, medication errors including crushing non-crushable meds and missed doses, lack of full-time certified dietary manager, serving unpalatable food, and poor infection control practices related to catheter care.

The facility failed to ensure staff immediately initiated CPR on Resident 1, who was a full code, after being found unresponsive on the floor. The delay in resuscitative measures placed Resident 1 and fifteen other residents with full code status in immediate jeopardy. Corrective measures including staff education and mock drills were completed prior to the survey.

The complaint investigation focused on Resident 1's wandering behavior and the facility's failure to provide adequate dementia care. The resident was found wandering into other residents' rooms multiple times, requiring frequent redirection and supervision. The facility's licensed social worker and family were involved in care planning due to increased wandering. The resident was at risk for injury and psychosocial impairment due to inadequate supervision and care.

The facility failed to provide necessary dementia care and services to Resident 1, who exhibited wandering behavior and required extensive assistance. This failure placed the resident at risk for decreased quality of life, safety, injury, and psychosocial impairment.

The facility had multiple deficiencies including failure to maintain resident dignity, inadequate care plan directions for fluid restrictions, lack of discharge summary, inconsistent bathing services, failure to provide activities for cognitively impaired residents, inadequate hydration monitoring, improper medication labeling, poor food preparation practices, and infection control lapses.

The facility identified deficiencies related to care plan accuracy, pressure ulcer prevention and treatment, and medication storage safety. Corrective actions include revising care plans, implementing weekly skin assessments, educating staff, and ensuring proper medication storage.

The visit was triggered by a complaint investigation #157471.

The facility failed to revise the care plan to include interventions to prevent pressure ulcers for one resident, and failed to provide timely assessment and interventions to prevent and treat pressure ulcers. Additionally, the facility failed to store emergency medications securely.

The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The plan references a complaint visit with findings related to transfer and discharge procedures. The plan of correction was submitted to address these findings.

The facility was cited for deficiencies related to transfer and discharge requirements, including involuntary discharge procedures. The plan outlines corrective actions to ensure compliance and prevent recurrence.

The complaint investigation #150879 focused on the facility's failure to properly manage an involuntary discharge of Resident 1, including inadequate notice, documentation, physician order, and placement efforts.

The facility failed to provide Resident 1 with an appropriate involuntary discharge notice, did not document an appropriate reason for the discharge, failed to obtain a discharge order from the resident's physician, and did not find a new facility to meet the resident's needs.

The facility identified deficiencies related to bathing care plans and documentation for residents. The plan includes reviewing and updating care plans, running weekly resident no-bath lists, and providing education to nursing staff to prevent recurrence.

The visit was complaint-related, investigating allegations regarding inadequate bathing and personal hygiene care for residents. The complaints were substantiated based on findings.

The facility failed to provide bathing services as care planned or requested for multiple residents, placing them at risk for poor hygiene. Observations, record reviews, and interviews confirmed that several residents did not receive showers or baths according to their care plans or preferences.

The facility failed to administer medications according to accepted standards for two residents, failed to meet the highest level of care for one resident regarding positioning, failed to ensure appropriate drug regimen reviews and monitoring for several residents, and failed to secure an expired emergency medication kit.

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

The report confirms that previously identified deficiencies under regulations 26-41-204(a), 26-41-102(d), and 26-41-105(f)(11) have been corrected as of 12/04/2018.

The report confirms that all previously cited deficiencies identified by regulation numbers 26-41-204 (a), 26-41-102 (d), and 26-41-105 (f)(11) have been corrected as of 12/04/2018.

The facility failed to provide or coordinate necessary health care services for a resident with recurring wounds, lacked evidence of criminal background checks for two certified medication aides, and failed to ensure complete documentation of incidents and wound care for the resident with skin conditions.

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.

Complaint #129258 was investigated and found to be unsubstantiated with no noncompliance identified.

The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.

The facility identified multiple deficiencies related to resident dignity, comprehensive assessments, care planning, wheelchair positioning, pressure ulcer prevention, environmental safety, medication diagnosis, and infection control. The Plan of Correction outlines corrective actions, staff education, auditing procedures, and ongoing monitoring to achieve substantial compliance by March 20, 2018.

The facility was cited for multiple deficiencies including failure to maintain resident dignity, incomplete assessments and care plans, inadequate care plan revisions, unsafe environment hazards, inappropriate medication use, and lack of an antibiotic stewardship program.

The facility identified multiple deficiencies related to care planning, skin assessments, hygiene, pressure ulcer prevention, range of motion, environmental safety, nutrition, medication management, staffing, and infection control. The plan outlines corrective actions including care plan revisions, staff education, audits, and monitoring systems to prevent recurrence.

The facility had multiple deficiencies including failure to develop comprehensive care plans, incomplete skin assessments, inadequate care for pressure ulcers, insufficient nursing staff, medication errors, and infection control issues.

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 survey found the most serious deficiencies to be at a 'D' level, indicating no harm but 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 report confirms that the deficiency identified under regulation 483.25(c) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.

This plan of correction is related to a complaint survey identified by Event ID 42KK11 and Complaint ID 090815.

The facility was cited for deficiencies related to prevention and treatment of pressure sores. The plan outlines corrective actions including care plan reviews, staff education, audits, and accountability measures to ensure compliance.

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 complaint was substantiated as the facility failed to prevent pressure ulcer development and did not follow scheduled skin assessment protocols.

The facility failed to provide adequate care to prevent the development of pressure ulcers and to promote healing for one resident. Specifically, the facility did not complete skin assessments under a knee immobilizer, which led to the development of a pressure ulcer.

The report confirms that the previously identified deficiency under regulation 483.12(a)(2) was corrected as of the revisit date.

The facility lacked required physician documentation related to involuntary discharges for Resident #1, which was subsequently obtained and added to the record. The facility plans to ensure compliance by obtaining required documentation prior to issuing discharge notices and reviewing documentation by administrators.

This visit was triggered by complaint investigation #89472. The complaint was substantiated as the facility did not have proper physician documentation to support the involuntary discharge of the resident.

The facility failed to obtain required physician documentation justifying the involuntary discharge of Resident #1, who was discharged due to endangering other residents by smoking while on oxygen. The resident suffered burns from the incident and the facility lacked physician documentation stating the resident was a danger to self or others.

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 is found to be in substantial compliance based on the credible allegation of compliance.

All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by 06/12/2015 as documented by the surveyor.

All deficiencies previously cited in the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by 06/12/2015 as documented in this report.

The facility identified multiple deficiencies related to resident care, including notification of family and physicians, fall investigations, care plan accuracy, pressure sore prevention, catheter care, medication administration, accident prevention, nutrition, and staffing. The facility outlined corrective actions, staff education, audits, and ongoing monitoring to achieve substantial compliance by June 12, 2015.

The facility had multiple deficiencies including failure to notify family and physicians of changes, inadequate investigation and reporting of falls and injuries, failure to promote dignity, incomplete assessments, inadequate care plans, failure to prevent pressure ulcers and weight loss, medication errors, and insufficient staffing and quality assurance.

The facility was found not in substantial compliance with participation requirements, constituting immediate jeopardy to resident health or safety related to pressure ulcers from February 16, 2015 through May 15, 2015. Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were recommended.

The revisit confirmed that the deficiencies identified in the prior survey were corrected by the revisit date of June 9, 2014.

This plan of correction is related to deficiencies cited in a complaint survey at Via Christi Village, Hays.

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

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

The survey was conducted in response to complaint #KS00074203. The complaint investigation found substantiated deficiencies related to failure to notify physicians and legal representatives of significant changes and failure to provide adequate care for skin conditions.

The facility failed to immediately inform the physician and/or resident's legal representative of significant changes in condition for 2 of 5 sampled residents. Additionally, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical well-being for 2 of 3 residents with skin conditions or open wounds.

The facility identified multiple deficiencies related to grievance resolution, admission assessments, comprehensive assessments, care plans, pressure ulcer prevention, urinary tract infection prevention, accident hazard prevention, psychotropic medication monitoring, nursing staff sufficiency, food safety, medication storage, and infection control. The facility has developed corrective actions including staff education, care plan reviews, audits, and monitoring processes.

The facility was found deficient in multiple areas including grievance resolution, comprehensive assessments, care planning, pressure ulcer prevention, infection control, medication management, staffing sufficiency, and food service sanitation.

The report shows that deficiencies previously cited 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 during a complaint investigation as indicated by the linked complaint ID and event.

The facility identified deficiencies related to communication with physicians regarding elevated temperatures and the need for updated care plans and interventions to prevent pressure ulcers. Corrective actions include staff education, auditing nursing documentation, and updating care plans for affected residents.

The report is based on complaint investigations #KS00072097 and #KS00071892.

The facility failed to immediately notify a physician of a significant change in a resident's condition and failed to provide necessary treatment and consistent wound care for residents with pressure ulcers, including failure to apply prescribed air boots and perform consistent wound assessments.

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

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

The facility failed to provide necessary bathing services to 4 sampled residents as per their care plans and preferences, resulting in poor grooming and hygiene. Additionally, the facility failed to respond timely to a door alarm leading to a stairwell, posing a safety hazard to cognitively impaired and independently mobile residents. Staffing shortages contributed to inadequate care and supervision.

This Plan of Correction is related to a complaint survey identified by Event ID 29NF11 and Complaint ID 2567.

The facility identified deficiencies related to bathing schedules, environmental safety including door alarms, and sufficient nursing staff to meet resident needs. The plan outlines corrective actions including staff education, audits, and quality assurance monitoring to ensure compliance.

The report confirms that all previously identified deficiencies under regulations 483.25, 483.25(m)(2), and 483.75(j)(1) were corrected by 07/18/2013.

The facility identified deficiencies related to monitoring vital signs and weights, medication administration, and timely laboratory services. The plan outlines re-education of clinical staff and compliance monitoring to ensure correction.

This investigation was triggered by complaint #KS00066524. The complaint was substantiated as the facility failed to provide necessary care and services, medication administration, and timely laboratory testing for sampled residents.

The facility failed to provide two sampled residents with necessary care including monitoring vital signs and weights as ordered by physicians. Additionally, the facility failed to ensure one resident remained free of significant medication errors and failed to obtain laboratory services in a timely manner, resulting in hospitalization.

The report shows that deficiencies identified in the prior survey were corrected as of the revisit date.

The facility identified deficiencies related to accident hazard prevention and sufficient nursing staff to meet resident needs. The plan includes re-education of clinical staff on mechanical lift transfers and call-light response, with compliance monitored by the quality assurance committee.

The complaint investigations #KS00064457 and #KS00064469 focused on accident hazards and staffing adequacy for mechanical lift transfers. The complaints were substantiated with findings of staff not following transfer policies and insufficient staffing.

The facility failed to ensure that residents' environments remained free of accident hazards due to staff not following the sit-to-stand lift policy, affecting residents #6 and #7. Additionally, the facility did not provide sufficient nursing staff to safely perform mechanical lift transfers, impacting 17 residents including the two sampled.

The report documents that previously identified deficiencies were corrected, with corrective actions completed on 01/04/2013 for two specific regulations.

The report confirms that deficiencies identified in the prior survey were corrected by the facility as of January 4, 2013.

All previously cited deficiencies listed on the CMS-2567 were corrected as of January 4, 2013, with no uncorrected deficiencies noted at the time of this revisit.

The plan outlines corrective actions for multiple deficiencies including provision of state advocacy contact information, maintaining survey results access, investigating un-witnessed injuries, dignified service provision, honoring resident choices, individualized care plans, comprehensive assessments, infection control, medication monitoring, sufficient staffing, and food safety.

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

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 in the dietary areas.

The report confirms correction of the previously cited deficiency identified by regulation 26-40-304 (d) with correction completed on 10/07/2011.

The facility failed to ensure that three exit doors to the building exterior had an adequate monitoring system. Exit doors had keypad locks with codes posted, allowing doors to be opened without proper alarm activation.