Inspection Reports for Diversicare of Chanute
530 W. 14TH STREET, KS, 66720-2877
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025, found no deficiencies, confirming the facility was in compliance with all regulations surveyed. Prior inspections had identified deficiencies related to psychotropic medication consent, environmental maintenance, nail care, and nursing staffing information posting, which were fully corrected by October 23, 2025. Earlier complaint investigations noted issues with resident care including wound and infection control, medication administration delays, dietary services, and supervision to prevent elopement, with corrective plans implemented and deficiencies addressed over time. Enforcement actions included a denial of payment for new admissions in 2015 and no fines or license suspensions were listed in the available reports. The facility’s inspection history shows a pattern of addressing cited deficiencies through plans of correction, with recent inspections indicating improvement and compliance.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
22.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
268% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
47 residents
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
A revisit survey was conducted on 11/19/25 to verify correction of all previous deficiencies cited on 09/23/25.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 10/23/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Oct 23, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility to address and correct deficiencies identified during a prior inspection.
Findings
The plan outlines corrective actions for deficiencies related to psychotropic medication informed consent, environmental repairs and cleaning, nail care provision, and nursing staffing information posting. The facility commits to audits and education to ensure compliance by 10/23/2025.
Deficiencies (4)
Psychotropic informed consent was not obtained and added to care plan for Resident #3 and potentially others.
Environmental issues including room repairs, repainting, vent cleaning, and fire safety device cleaning.
Nail care was not provided appropriately to Resident #5 and potentially others.
Nursing staffing information, including hours worked per shift, was not posted daily as required.
Report Facts
Resident charts audited weekly: 3
Resident charts audited weekly: 5
Audit frequency: 4
Audit duration: 3
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 4
Date: Sep 23, 2025
Visit Reason
The inspection was an extended Health Recertification Survey and complaint survey regarding allegations in cases 2619946, 575460, and 2578024.
Complaint Details
The survey included complaint allegations in cases 2619946, 575460, and 2578024. The findings relate to informed consent, environment safety, resident care, and staffing information.
Findings
The facility failed to ensure informed consent for psychotropic medications for one resident, failed to maintain a safe, clean, and homelike environment in resident rooms and common areas, failed to provide nail care for a resident, and failed to post accurate nurse staffing information daily.
Deficiencies (4)
Failure to ensure informed consent for psychotropic medications for one resident.
Failure to maintain a safe, clean, and homelike environment including peeling paint, exposed wood, damaged blinds, and unknown organic substances on vents and ceilings.
Failure to provide nail care for one resident unable to carry out activities of daily living.
Failure to post accurate and identifiable nurse staffing information daily for 47 residents.
Report Facts
Resident census: 47
Sample residents reviewed: 15
Medication dosages: 40
Medication dosages: 100
Medication dosages: 15
Medication dosages: 0.25
Dates: Jul 28, 2025
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 09/17/2025.
Findings
All deficiencies have been corrected as of the compliance date of 09/13/2025, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Compliance date: Sep 13, 2025
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Jul 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints numbered 1587363 and 1587358 regarding residents' rights to communication and dietary services.
Complaint Details
The investigation was triggered by complaints regarding residents not receiving mail on Saturdays and dissatisfaction with dietary services including food temperature, quality, and variety. The complaints were substantiated with observations and interviews confirming mail delivery issues and ongoing dietary concerns.
Findings
The facility failed to provide residents with reasonable access to receive mail on Saturdays, violating their right to communication. Additionally, the facility failed to provide food that was nutritionally balanced, palatable, attractive, and served at safe and appetizing temperatures, leading to resident dissatisfaction and risk of inadequate nutrition.
Deficiencies (2)
Failure to provide residents reasonable access to receive mail, especially on Saturdays.
Failure to provide food that was nutritionally balanced, palatable, attractive, and served at safe and appetizing temperatures.
Report Facts
Census: 44
Temperature: 127
Temperature: 119
Temperature: 77
Date: Jul 1, 2012
Date: Jan 1, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Staff Z | Activity Staff | Reported mail delivery process and resident complaints about dietary and mail delivery. |
| Certified Medication Aide R | Certified Medication Aide | Reported mail delivery issues and uncertainty about mail delivery on weekends. |
| Licensed Nurse H | Licensed Nurse | Observed mail delivery during the week and reported resident complaints about food. |
| Administrative Staff A | Administrative Staff | Confirmed residents' right to receive mail on Saturdays and acknowledged dietary concerns. |
| Dietary Staff BB | Dietary Staff | Tested food temperatures and reported on food palatability and meal delivery issues. |
| Dietary Staff CC | Dietary Staff | Reported on resident concerns, food substitutions, and communication with dietary management. |
| Administrative Nurse D | Administrative Nurse | Confirmed dietary service contract and ongoing dietary concerns. |
| Licensed Nurse G | Licensed Nurse | Delivered meal trays with CNA and reported resident complaints about food. |
| Certified Nurse Aide N | Certified Nurse Aide | Delivered meal trays with Licensed Nurse and reported resident complaints about food. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 30, 2025
Visit Reason
This Plan of Correction document addresses deficiencies cited during a prior survey conducted on 2025-07-30 and outlines corrective actions the facility will implement to ensure compliance with regulations.
Findings
The facility submitted corrective actions for deficiencies related to Saturday mail delivery and meal delivery systems, including education of residents and staff, auditing processes, and updates to procedures to ensure compliance and proper service.
Deficiencies (2)
Residents and responsible parties educated on Saturday mail delivery process; Manager on Duty responsible for mail delivery on Saturdays; audits to ensure completion.
Meal delivery system reviewed and modified to ensure food served at appropriate temperatures; dietary staff educated on food temperature and substitution logging; audits to ensure compliance.
Report Facts
Audit frequency: 5
Audit duration: 4
Audit duration: 3
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 06/25/24.
Findings
All deficiencies cited in the previous inspection have been corrected as of 07/11/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 5
Date: Jun 25, 2024
Visit Reason
Complaint investigation #KS00188676 regarding quality of care and infection control issues at Diversicare of Chanute.
Complaint Details
Complaint investigation #KS00188676 focused on quality of care issues including wound care and infection control.
Findings
The facility failed to ensure Resident 1 had clean, dry dressings and timely treatment, resulting in maggots found on his leg. The facility also failed to follow physician orders for wound care for Resident 4, failed to monitor and treat constipation for Resident 3, and failed to maintain effective infection control and pest control programs.
Deficiencies (5)
Failed to ensure Resident 1 had clean and dry dressings to lower extremities; maggots found on 06/17/24.
Failed to provide appropriate wound treatment as ordered for Resident 4; ointment applied instead of Dermafoam dressing.
Failed to monitor bowel function and notify physician for Resident 3 who had constipation for five days without treatment.
Failed to maintain effective infection prevention and control program; improper hand hygiene and dressing change observed for Resident 1.
Failed to maintain effective pest control program; maggots found on Resident 1 and flies observed in his room.
Report Facts
Census: 46
Residents reviewed: 4
Days without bowel movement: 5
Date of inspection: Jun 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant Staff GG | Discovered maggots on Resident 1's leg on 06/17/24. | |
| Licensed Nurse G | Licensed Nurse | Performed dressing changes on Resident 1 with improper hand hygiene and handling. |
| Administrative Nurse D | Administrative Nurse | Responsible for wound care orders and communication with outpatient therapy. |
| Administrative Nurse E | Administrative Nurse | Provided instructions on dressing changes and infection control. |
| Licensed Nurse H | Licensed Nurse | Involved in dressing changes and reported maggot findings. |
| Licensed Nurse J | Licensed Nurse | Reported maggot findings and fly presence in Resident 1's room. |
| Licensed Nurse I | Licensed Nurse | Cared for Resident 1 during night shifts and reported dressing condition. |
| Certified Nurse Aide O | Certified Nurse Aide | Reported Resident 3's constipation to nursing staff. |
| Maintenance Staff V | Maintenance Staff | Notified of pest control issues and fly presence. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jun 25, 2024
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Chanute in response to deficiencies cited during a survey conducted on June 25, 2024.
Findings
The plan addresses multiple deficiencies related to wound care, bowel movement documentation, infection control, and pest control. The facility outlines corrective actions including staff education, audits, and ongoing monitoring to ensure compliance with standards.
Deficiencies (5)
Wound care was provided for resident R1 with physician orders for treatment when dressing becomes soiled.
Resident R4 was provided wound treatment as ordered; audits ensured correct treatment.
Physician was notified of resident R3’s bowel patterns and medication was adjusted appropriately.
Clean dressing changes completed on resident R1 with infection control practices maintained.
Resident room R1 was treated for pests; rooms audited and treated appropriately.
Report Facts
Audit frequency: 5
Audit duration: 4
Audit duration: 3
Pest control audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Roby | Administrator | Submitted the Plan of Correction |
| Teresa Edwards | Added and modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
An offsite revisit survey was conducted on 04/23/24 for all previous deficiencies cited on 03/21/24 to verify correction of cited deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 04/03/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
An offsite revisit survey was conducted on 04/23/24 to verify correction of all previous deficiencies cited on 03/04/24.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 03/29/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: 0
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Mar 29, 2024
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Chanute in response to deficiencies cited during a survey inspection.
Findings
The Plan of Correction addresses multiple deficiencies including environmental issues, care plan timing and revision, range of motion/mobility, accident hazards and supervision, dialysis documentation, nurse aide performance review, pharmacy services, drug regimen monitoring, food procurement sanitation, and payroll based journal data accuracy. Corrective actions include repairs, staff education, audits, and ongoing monitoring with results submitted to the Quality Assurance Committee.
Deficiencies (10)
Environmental items such as torn floor mats, missing tiles, unmade beds, and damaged door molding were corrected.
Care plans were updated for timely interventions related to falls and blood pressure medication parameters.
Range of motion and mobility assessments and restorative therapy documentation were updated and monitored.
Care plans updated to prevent accident hazards and ensure supervision and assistive devices are in place.
Dialysis documentation and post dialysis communication sheets are being collected and reviewed.
Nurse aide annual performance reviews and evaluations are being audited.
Pharmacy services including blood sugar parameter monitoring and physician notification were addressed.
Drug regimen monitoring to avoid unnecessary drugs and ensure physician notification for BP medication.
Food procurement sanitation issue corrected by ensuring a two-inch air gap on ice machine drain.
Payroll Based Journal data audited for accuracy and staff educated on submission requirements.
Report Facts
Care plans audited weekly: 5
Nurse aide staff files audited weekly: 2
Residents audited for BS parameters: 3
Residents audited for EMAR vital sign monitoring: 3
Restorative notebooks audited weekly: 5
Dialysis communication sheets reviewed: 4
Fall interventions audited weekly: 4
Ice machine air gap audit weekly: 4
Licensed nurse staffing data audit weekly: 4
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation (#KS00186602) focusing on respiratory care and medication administration at Diversicare of Chanute.
Complaint Details
The visit was triggered by complaint investigation #KS00186602. The complaint involved concerns about respiratory care and medication administration errors.
Findings
The facility failed to administer physician-ordered oxygen correctly for two residents, resulting in inadequate oxygen delivery and empty oxygen tanks. Additionally, the facility failed to start a prescribed anticoagulant medication (Eliquis) for Resident 1 for 22 days after the order, and did not notify the cardiologist about the fistula placement appointment for medication management.
Deficiencies (2)
Failed to administer physician ordered oxygen to Resident 5 and ensure Resident 1's oxygen tank did not run empty or deliver oxygen as prescribed.
Failed to start a physician ordered anticoagulant medication (Eliquis) for Resident 1, resulting in 22 days without the medication.
Report Facts
Census: 49
Residents reviewed: 5
Days medication delayed: 22
Oxygen liters ordered for Resident 5: 3
Oxygen liters observed for Resident 5: 3.5
Oxygen liters ordered for Resident 1: 2
Oxygen liters observed for Resident 1: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Stated Resident 5's oxygen was to be set at four liters and admitted not checking orders daily |
| Administrative Nurse D | Administrative Nurse | Stated staff should follow physician orders for oxygen and ensure residents have enough oxygen for appointments |
| Licensed Nurse G | Licensed Nurse | Assisted Resident 1 with oxygen and noted Resident 1's habit of pulling nasal cannula off |
| Certified Medication Aide R | Certified Medication Aide | Reported Resident 1 often returned from dialysis with empty oxygen bottle or bottle not turned on |
| Consultant Staff HH | Consultant Staff | Observed Resident 1's low oxygen saturation and empty oxygen tank at appointment |
| Consultant Staff GG | Consultant Staff | Confirmed Resident 1 did not have Eliquis on medication list at appointment |
| Administrative Staff A | Administrative Staff | Reported family concerns about Resident 1's oxygen bottle being empty |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 21, 2024
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on March 21, 2024.
Findings
The facility addressed deficiencies related to respiratory/tracheostomy care and pharmacy services, including oxygen settings and initiation of physician orders. Staff education and ongoing audits were planned to ensure compliance.
Deficiencies (2)
Respiratory/Tracheostomy Care and Suctioning - oxygen settings not properly followed
Pharmacy/Services/Procedures/Pharmacist/Records - initiation of physician orders not properly followed
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 10
Date: Mar 4, 2024
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements and investigate complaints.
Complaint Details
The inspection included a complaint investigation #185790.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; failure to timely revise care plans after falls and medication changes; failure to provide restorative services; failure to initiate appropriate interventions after falls; failure to complete post dialysis assessments; failure to complete annual performance reviews for staff; failure to notify physicians of abnormal blood sugars; failure to hold hypertensive medications when indicated; failure to maintain food safety standards; and failure to accurately submit payroll-based staffing data.
Deficiencies (10)
Facility failed to maintain a safe, sanitary, and homelike environment with issues such as torn floor mats, stained tiles, missing tiles in shower, unmade beds, broken door guards, and dusty vents.
Failure to develop and revise comprehensive care plans timely for residents after falls and medication changes.
Failure to provide restorative services to a resident with impairments in function to maintain range of motion.
Failure to initiate appropriate interventions following non-injury falls for residents at high risk for falls.
Failure to ensure licensed staff completed post dialysis vital signs and access site assessments for a resident after dialysis treatments.
Failure to complete annual performance reviews for multiple Certified Nurse Aides and Certified Medication Aides.
Failure to follow physician's orders for notifying physician of blood sugars outside parameters for a diabetic resident.
Failure to ensure drug regimen free from unnecessary drugs by not holding hypertensive medications when blood pressure was outside ordered parameters.
Failure to maintain a two-inch air gap between the ice machine drainpipe and kitchen drain to prevent contamination.
Failure to electronically submit complete and accurate direct care staffing information to CMS, including inaccurate weekend staffing data.
Report Facts
Resident census: 50
Residents in sample: 17
Non-injury falls: 2
Certified Nurse Aides without annual review: 3
Certified Medication Aides without annual review: 2
Blood sugar readings above 400: 12
Dates missing post dialysis assessment: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including failure to initiate fall interventions, failure to complete post dialysis assessments, and failure to complete annual staff reviews |
| Licensed Nurse G | Licensed Nurse | Named in findings related to fall interventions and medication administration |
| Certified Medication Aide S | Certified Medication Aide | Named in medication administration and blood pressure monitoring |
| Certified Nurse Aide P | Certified Nurse Aide | Named in fall supervision and resident safety |
| Maintenance Staff U | Maintenance Staff | Named in environmental safety and maintenance findings |
| Housekeeping Staff V | Housekeeping Staff | Named in environmental cleanliness findings |
| Consulting Therapy Staff GG | Consulting Therapy Staff | Named in restorative services findings |
| Consultant Therapy Staff HH | Consultant Therapy Staff | Named in restorative services findings |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 26, 2022
Visit Reason
The revisit survey was conducted on 07/26-28/2022 to verify correction of all previous deficiencies cited on 05/25/2022.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 07/01/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 25, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in the inspection report dated 2022-05-25 for Diversicare of Chanute.
Findings
The document indicates that the Plan of Correction is currently a Work In Progress (WIP) status related to the cited deficiencies from the inspection.
Report Facts
Inspection report date: May 25, 2022
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 13
Date: May 25, 2022
Visit Reason
Health Resurvey and Complaint Investigations for multiple complaint numbers.
Findings
The facility had multiple deficiencies including failure to provide sanitary dressing changes, failure to prevent pressure ulcers, inadequate fall interventions, improper handling of urinary catheter bags, failure to follow dialysis center communications, insufficient nursing staff, medication administration errors, unpalatable food, failure to provide physician-ordered therapeutic diets, unsanitary food storage and preparation, inadequate infection control practices, failure to provide COVID-19 vaccine education, and unsafe kitchen oven temperatures.
Deficiencies (13)
Failed to provide sanitary dressing change for resident with osteomyelitis and amputation site, including failure to sanitize scissors and hands during dressing change.
Failed to ensure appropriate treatment and services to prevent development of unstageable pressure ulcer for resident with dementia and diabetes.
Failed to initiate appropriate fall interventions for resident with history of falls and confusion, and failed to ensure bariatric shower chair was safe.
Failed to appropriately handle urinary catheter bag during cares, including tubing resting on floor and failure to cleanse catheter nozzle.
Failed to ensure follow-up on dialysis center communications including diet orders and lidocaine cream application.
Failed to provide sufficient nursing staff to ensure resident safety and timely medication administration.
Failed to ensure timely administration of insulin and potassium supplement medications as ordered.
Failed to provide palatable meals; residents reported cold and undercooked food, limited variety, and repetitive menus.
Failed to provide physician ordered therapeutic renal diet for resident receiving dialysis.
Failed to store, prepare, and serve food in a sanitary manner including improper storage of clean items and lack of air gap on ice machine drain.
Failed to maintain proper infection control practices during wound dressing changes and urinary catheter care.
Failed to provide COVID-19 vaccination education including benefits and risks to residents prior to vaccine declination.
Failed to maintain kitchen ovens at consistent and adequate temperatures for safe food preparation.
Report Facts
Census: 54
Residents sampled: 17
Potassium doses missed: 10
Potassium doses documented administered but unavailable: 16
Insulin doses administered late: 42
Oven temperature right side: 402
Oven temperature left side: 388
Oven temperature left side max: 410
COVID-19 unvaccinated residents: 11
COVID-19 residents with delayed declination: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in unsanitary dressing change and failure to apply lidocaine cream properly. |
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including infection control, dialysis communication follow-up, and COVID-19 education. |
| CNA O | Certified Nurse Aide | Named in failure to cleanse catheter nozzle during urinary catheter care. |
| LN I | Licensed Nurse | Named in infection control failure during pressure ulcer dressing change and catheter care. |
| LN H | Licensed Nurse | Named in late insulin administration and staffing concerns. |
| CMA R | Certified Medication Aide | Named in potassium medication reorder and administration issues. |
| Dietary Staff BB | Dietary Staff | Named in food quality and oven temperature findings. |
| Dietary Staff CC | Dietary Staff | Named in oven temperature findings. |
| Maintenance Staff U | Maintenance Staff | Named in oven temperature and food storage findings. |
| Administrative Staff A | Administrative Staff | Named in insulin administration timing and staffing issues. |
| Administrative Nurse A | Administrative Nurse | Named in insulin administration timing and staffing issues. |
| Dietary Consultant GG | Dietary Consultant | Named in dietary assessment findings. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 5, 2022
Visit Reason
An offsite revisit survey was conducted on 01/05/2022 for all previous deficiencies cited on 12/02/2021.
Findings
All deficiencies have been corrected as of the compliance date of 12/14/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 14, 2021
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey of the facility.
Findings
The facility addressed deficiencies related to staff qualifications, specifically regarding medication administration by LPN, LPN G, and CNA M. Education was provided, residents were assessed for adverse effects, and ongoing monitoring and training plans were established to ensure compliance.
Deficiencies (1)
Staff qualifications related to medication administration were deficient.
Report Facts
Complete Date: Dec 14, 2021
Education Date: Nov 29, 2021
Audit Frequency: 4
Audit Frequency: 3
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Dec 2, 2021
Visit Reason
The inspection was conducted as a result of complaint investigations #157758, #167477, and #167533 regarding staff qualifications and medication administration.
Complaint Details
The findings represent the results of complaint investigations #157758, #167477, and #167533. The complaint was substantiated as the facility allowed a non-certified CNA to administer medications, which is against state certification requirements.
Findings
The facility failed to ensure that only qualified certified medication staff administered medications to residents on the west unit. Specifically, a Certified Nurse Aide (CNA M) who was not certified as a Certified Medication Aide administered medications to 20 residents on Thanksgiving Day, November 25, 2021, under the supervision of a Licensed Nurse (LN G).
Deficiencies (1)
Facility failed to ensure only qualified certified medication staff administered medication to residents on the west unit on 11/25/21.
Report Facts
Resident census: 46
Residents on west unit: 20
Hours of CMA training completed: 75
CMA certification expiration: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Supervised medication administration by non-certified CNA on 11/25/21 |
| CNA M | Certified Nurse Aide | Administered medications without CMA certification on 11/25/21 |
| Administrative Nurse D | Informed about CNA M administering medications and communicated with staff | |
| CMA S | Certified Medication Aide | Scheduled to pass medications on 11/25/21 but was a no call no show |
| Administrative Staff A | Interviewed regarding medication administration incident |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 6, 2021
Visit Reason
An offsite revisit survey was conducted on 08/06/21 for all previous deficiencies cited on 07/01/21.
Findings
All deficiencies have been corrected as of the compliance date of 08/01/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 1, 2021
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Chanute in response to deficiencies cited in a prior inspection related to abuse/neglect reporting, investigation, and medication storage.
Findings
The Plan of Correction addresses termination of an LPN involved in alleged violations, reeducation of staff on abuse/neglect policies, monthly interviews and audits related to abuse/neglect, and improvements in medication storage procedures including securing medications awaiting destruction.
Deficiencies (3)
Failure to timely report alleged violations of abuse/neglect/misappropriation.
Failure to properly investigate alleged violations of abuse/neglect/misappropriation.
Improper label and storage of drugs and biologicals.
Report Facts
Date of LPN termination: Jun 4, 2021
Audit frequency: 4
Audit duration: 3
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 3
Date: Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#KS 00162982) regarding allegations of potential drug diversion (theft) of residents' narcotic medications.
Complaint Details
The complaint investigation was triggered by allegations of drug diversion (theft) of narcotic medications by Licensed Nurse I. The facility failed to report the allegation timely and did not conduct a thorough investigation, lacking witness statements and resident interviews. The drug screen of the alleged perpetrator was negative, but monitoring was insufficient. The medication storage was found to be insecure, facilitating potential diversion.
Findings
The facility failed to immediately report the allegation of drug diversion to the State Agency and did not thoroughly investigate the allegation. Additionally, the facility failed to ensure safe and secure storage of controlled medications, as the narcotic medication lock box was structurally compromised allowing potential unauthorized access.
Deficiencies (3)
Failed to report an allegation of potential drug diversion (theft) of residents' narcotic medications to the State Agency as required.
Failed to thoroughly investigate an allegation of potential drug diversion (theft) of residents' narcotic medications.
Failed to ensure safe and secure storage of residents' controlled medications in a structurally secure, locked cabinet to prevent loss or diversion (theft) by facility staff.
Report Facts
Census: 47
Date of drug screen: Feb 20, 2021
Date of receipt for metal mail flap: Jun 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse I | Licensed Nurse | Alleged perpetrator of drug diversion. |
| Licensed Nurse G | Licensed Nurse | Reported concerns about LN I stealing medications. |
| Administrative Nurse D | Director of Nursing | Received reports about LN I and handled investigation. |
| Certified Medication Aide R | Certified Medication Aide | Reported unsafe medication storage and demonstrated vulnerability. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
A revisit survey was conducted on 11/30/2020 - 12/01/2020 for all previous deficiencies cited on 09/01/2020.
Findings
All deficiencies have been corrected as of the compliance date of 09/28/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 11
Date: Sep 1, 2020
Visit Reason
The inspection was a Health Resurvey and Complaint investigation involving multiple complaint investigations and a resurvey of the facility.
Complaint Details
The inspection included complaint investigations #154623, #153170, and #150316.
Findings
The facility was found deficient in multiple areas including failure to provide written bed-hold notice upon hospital transfer, inaccurate resident assessments, failure to develop and implement comprehensive care plans, inadequate restorative services, failure to provide appropriate oral hygiene, improper treatment of pressure ulcers, failure to maintain range of motion, improper respiratory equipment cleaning and maintenance, failure to provide individualized nurse aide in-service training, failure to act on pharmacy recommendations, and ineffective quality assurance processes.
Deficiencies (11)
Failed to provide written notice specifying the duration of the bed-hold policy at the time of resident transfer to hospital.
Failed to complete accurate comprehensive assessments for residents, including inaccurate documentation of range of motion and psychotropic medication use.
Failed to develop and implement individualized comprehensive care plans for residents, including restorative care and oxygen therapy.
Failed to provide appropriate oral hygiene care for a dependent resident.
Failed to ensure appropriate treatment and services to prevent and treat pressure ulcers, including failure to prevent development of four stage II pressure ulcers and worsening of another pressure ulcer.
Failed to provide restorative services to maintain or improve range of motion, resulting in increased contractures and need for increased muscle relaxant medication.
Failed to ensure proper cleaning and maintenance of respiratory equipment including oxygen concentrator filters and tubing, increasing risk of respiratory infections.
Failed to provide individualized nurse aide in-service training based on performance reviews.
Pharmacy failed to identify medication irregularities related to pulse monitoring and facility failed to act on consultant pharmacist recommendations for multiple residents.
Failed to administer antihypertensive medications appropriately when resident's pulse was out of physician ordered parameters, risking unnecessary medication use.
Failed to maintain an effective Quality Assessment and Assurance program to identify and correct quality deficiencies in care and services.
Report Facts
Residents sampled: 17
Medication administration out of parameters: 32
Duration of missed restorative services: 10
Days oxygen tubing not changed: 43
Stage II pressure ulcers developed: 4
Pressure ulcer size: 3.5
Pressure ulcer size: 3
Pressure ulcer size: 0.9
Pressure ulcer size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Responsible for sending pharmacy consultant recommendations to physicians; confirmed failure to send some recommendations. |
| Consultant Pharmacist GG | Pharmacist | Conducted pharmacy reviews; failed to identify medication irregularities related to pulse monitoring. |
| Licensed Nurse G | Licensed Nurse | Observed pressure ulcer treatments and oxygen equipment; stated uncertainty about restorative care provision. |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on oral care provision and oxygen equipment cleaning practices. |
| Administrative Staff A | Administrative Staff | Reported on Quality Assessment and Assurance Committee meetings and deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Sep 1, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 09/01/2020.
Findings
The Plan of Correction outlines corrective actions taken or planned for multiple deficiencies related to resident care, documentation, staff education, and policy compliance, with audits and monitoring scheduled to ensure compliance by 09/28/2020.
Deficiencies (11)
Failure to follow bed hold policy for resident #31 discharged and returned from hospital.
Inaccurate completion of significant change of status MDS for residents #44 and #49.
Incomplete or outdated care plans for residents including #44 and #15.
Oral hygiene needs not consistently met for resident #44 and others.
Wound care and skin assessments not adequately documented or interventions incomplete for resident #44.
Restorative therapy assessments and documentation incomplete for residents #44, #32, and #6.
Oxygen concentrator filters and tubing not cleaned or replaced as required for residents #11, #35, #19, and #27.
Annual performance evaluations for nurse aides not timely completed.
Pharmacy recommendations not reviewed and acted upon timely for residents #11, #31, #35, #6, and #49.
Medications requiring parameters not reviewed or administered properly for resident #49.
QAPI meetings not effectively identifying and addressing care and service issues.
Report Facts
Audit frequency: 5
Audit duration: 4
Audit duration: 3
Plan of Correction completion date: Sep 28, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Evelyn Lacey | RN QIC | Submitted the Plan of Correction to KDADS |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 10, 2020
Visit Reason
A non-compliance revisit for the Targeted Infection Control/Covid-19 survey was conducted on 08/10/2020 to verify correction of all previous deficiencies cited on 06/17/2020.
Findings
All deficiencies cited in the previous survey have been corrected as of 07/02/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous survey date: Jun 17, 2020
Compliance date: Jul 2, 2020
Inspection Report
Abbreviated Survey
Census: 54
Deficiencies: 1
Date: Jun 17, 2020
Visit Reason
A Targeted Infection Control/COVID-19 Survey was conducted by Kansas Department for Aging and Disability Services (KDADS) on behalf of CMS from 06/15/2020 through 06/17/2020 to assess the facility's infection prevention and control practices related to COVID-19.
Findings
The facility failed to perform appropriate staff screening including temperature checks on 42 occasions, allowing staff to work with temperatures of 100.0 degrees Fahrenheit or greater on four occasions, placing residents at immediate jeopardy. The facility implemented a plan of removal including staff education and enhanced screening procedures, which was validated by the survey team.
Deficiencies (1)
Failure to perform appropriate staff screening including temperature checks on 42 occasions and allowing staff to work with temperatures of 100.0 degrees Fahrenheit or greater.
Report Facts
Staff screening omissions: 42
Staff working with elevated temperature: 4
Resident census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse G | Infection Control Nurse | Identified herself as infection control nurse and reported staff screening procedures |
| Administrative Nursing Staff D | Reported staff screening procedures and verified temperature monitoring failures | |
| Administrative Staff A | Informed of immediate jeopardy status and involved in plan of correction | |
| Licensed Nurse G | Observed entering building and completing self-temperature screening |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 17, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a COVID-19 related inspection at Diversicare Chanute on 6/17/2020.
Findings
The plan outlines immediate actions taken to educate and screen all staff on infection control, handwashing, PPE use, and visitor screening. It includes ongoing audits, staff education, and involvement of the Administrator, DNS, and Medical Director to ensure compliance and monitoring.
Deficiencies (1)
Failure to properly screen and educate staff on infection control, handwashing, PPE use, and essential visitor screening.
Report Facts
Date of staff screening and education: Jun 16, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brad Fischer | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 14, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-11-26.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2019-12-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Nov 26, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#147644) regarding the facility's failure to provide timely repositioning to prevent pressure ulcers in a resident.
Complaint Details
The complaint investigation (#147644) found the facility failed to reposition a resident as required, substantiated by observations and staff interviews confirming the resident was left in the same position for extended periods.
Findings
The facility failed to timely reposition one resident who required assistance, resulting in pressure ulcer risk. Observations confirmed the resident remained in the same position for over four hours and again for over two hours without repositioning, contrary to the care plan and facility policy.
Deficiencies (1)
Failure to timely reposition a resident to prevent pressure ulcer development.
Report Facts
Resident census: 48
Time resident remained without repositioning: 265
Time resident remained without repositioning: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Reported that the resident remained in the wheelchair all morning without repositioning. | |
| Certified Nurse Aides D, G, H, I | Confirmed failure to reposition the resident since breakfast on 11/21/19. | |
| Certified Nurse Aides E and F | Assisted resident into bed after prolonged time without repositioning. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 21, 2019
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during a prior inspection on 11-21-2019 related to resident care and skin assessments.
Findings
Deficiencies involved failure to properly reposition residents, perform incontinent care, and maintain skin assessments. The facility implemented corrective actions including staff education, updated skin assessment schedules, and ongoing audits.
Deficiencies (1)
Failure to reposition residents promptly and perform incontinent care; inadequate skin assessment and documentation.
Report Facts
Deficiency completion date: Dec 13, 2019
Deficiency identification date: Nov 21, 2019
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 3, 2019
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-08-08.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2019-08-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Date: Aug 8, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#144151) regarding concerns about inadequate bathing assistance and restorative services for dependent residents.
Complaint Details
The complaint investigation #144151 was triggered by family concerns regarding lack of bathing and restorative care for residents, specifically citing failure to provide showers and range of motion exercises as scheduled.
Findings
The facility failed to provide adequate bathing assistance and restorative range of motion (ROM) services as recommended by therapy for four sampled residents. Additionally, the facility lacked sufficient nursing staff to provide necessary care and supervision, including bathing and restorative services.
Deficiencies (3)
Failed to provide adequate bathing assistance for four sampled dependent residents.
Failed to provide restorative services to prevent decrease in range of motion for four sampled residents as recommended by therapy.
Failed to have sufficient nursing staff to provide adequate care and services including bathing and restorative services.
Report Facts
Census: 58
Days without bathing: 5
Days without bathing: 6
Days without bathing: 6
Days without bathing: 5
Days without bathing: 5
Days without bathing: 5
Days without bathing: 5
Minutes of PROM: 5
Minutes of PROM: 15
Minutes of PROM: 20
Minutes of PROM: 15
Residents: 4
Licensed nurse on duty: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service J | Social Service | Reported lack of manager supervisor on 08/04/19. |
| Licensed Nurse C | Licensed Nurse | Reported inability to find certified staff replacement on 08/04/19. |
| Administrative Staff A | Acknowledged lack of supervisor on 08/04/19 and was unavailable to assist with staffing. | |
| Administrative Nurse B | Administrative Nurse | Failed to answer phone multiple times and was unavailable to assist with staffing. |
| Certified Nurse Aide H | Certified Nurse Aide | Verified staff did not have time to complete all resident baths as scheduled. |
| Certified Nurse Aide I | Certified Nurse Aide | Verified staff did not have time to complete all resident baths as scheduled. |
| Certified Nurse Aide E | Certified Nurse Aide | Reported lack of time to provide recommended PROM for Resident 1. |
| Certified Nurse Aide F | Certified Nurse Aide | Reported lack of time to provide recommended PROM for Resident 1. |
| Therapist G | Therapist | Reported lack of joint measurements to support decline or maintenance of movement and restorative program recommendations. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 8, 2019
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Chanute in response to deficiencies cited during a prior inspection on August 8, 2019.
Findings
The plan outlines corrective actions addressing deficiencies related to residents' ADL care needs, restorative therapy programs, and staffing schedules, with education and audits planned to ensure compliance by August 28, 2019.
Deficiencies (3)
Residents #1, #2, #3 and #4 were re-interviewed and assessed regarding their ADL care needs; care plans updated accordingly.
Residents #1, #2, #3, and #4 referred to therapy for assessment for ROM restorative plan; ongoing assessments and documentation audits planned.
Staffing schedules reviewed and adjusted to meet patient and resident needs; interdisciplinary team re-educated on staffing levels.
Report Facts
Deficiency completion date: Aug 28, 2019
Resident interviews: 3
Documentation audits: 3
Staffing review meetings: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Chidomukwindidza | Administrator | Submitted the Plan of Correction |
| Evelyn Lacey | Added the Plan of Correction | |
| Diana Melander | Modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 20, 2019
Visit Reason
A revisit survey was conducted from 2019-05-15 to 2019-05-20 to verify correction of all previous deficiencies cited on 2019-03-21.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2019-04-23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: Mar 21, 2019
Compliance date: Apr 23, 2019
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 20, 2019
Visit Reason
A revisit survey was conducted from 2019-05-15 to 2019-05-20 to verify correction of all previous deficiencies cited on 2019-03-21.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2019-04-23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 2, 2019
Visit Reason
An abbreviated survey was conducted on May 2, 2019 by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy and identified past non-compliance for F689, "G", CFR 483.25(d)(1)(2). Due to this and prior non-compliance, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.
Deficiencies (1)
Deficiency cited for F689, "G", CFR 483.25(d)(1)(2) at a level of actual harm that is not immediate jeopardy
Report Facts
Denial of payment effective date: Apr 19, 2019
Compliance deadline: Sep 21, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter and contact for questions concerning the instructions |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: May 2, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#140700) related to an accident involving a resident during facility van transportation.
Complaint Details
The visit was triggered by complaint investigation #140700. The resident fell out of the wheelchair during transport when the restraint belt became unhooked. The resident sustained injuries including fractures and lacerations. The facility was cited for past non-compliance with no prior plan of correction.
Findings
The facility failed to provide safe van transportation for one resident, resulting in the resident falling out of a wheelchair during transport due to the lap and shoulder restraint belt becoming unhooked from the floor track. The resident sustained multiple injuries including maxillary sinus fractures, facial lacerations, bruising, and skin tears. The facility identified debris in the van floor tracks as the cause and took immediate corrective actions including van cleaning, staff re-education, and implementation of pre-trip inspections.
Deficiencies (1)
Failed to provide safe facility van transportation resulting in resident injury due to lap and shoulder restraint belt becoming unhooked from the floor track.
Report Facts
Resident census: 58
Sampled residents for accidents: 3
Date of incident: Apr 22, 2019
Injury measurements: 2
Injury measurements: 1.5
Injury measurements: 4
Injury measurements: 2.5
Injury measurements: 1
Injury measurements: 0.1
Injury measurements: 1
Injury measurements: 1
Injury measurements: 0.5
Injury measurements: 1
Date of facility policy: Jun 19, 2013
Date of QAPI meeting: Apr 22, 2019
Frequency of observation: 2
Duration of observation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Driver involved in the transport incident and provided facility Vehicle Safety Program Guidelines. | |
| Facility nurse B | Assessed the resident after the accident and documented injuries. | |
| Vehicle dealership maintenance supervisor C | Reported results of van inspection after the incident. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 18
Date: Mar 21, 2019
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation triggered by complaints #139266, #139278, and #139478, focusing on resident dignity, safe environment, reporting of alleged violations, and other compliance issues.
Complaint Details
The visit was complaint-related as it included a complaint investigation triggered by complaints #139266, #139278, and #139478.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, unsafe and unsanitary environment conditions, failure to report and investigate abuse allegations timely, incomplete and untimely resident assessments and care plans, inadequate restorative nursing services, insufficient staffing, failure to provide scheduled showers and grooming, lack of activities meeting resident preferences, failure to implement fall prevention interventions, and failure to monitor side effects of psychotropic medications.
Deficiencies (18)
Failure to ensure residents were treated with respect and dignity, including a staff member speaking rudely to a resident.
Failure to provide a safe, clean, comfortable, and homelike environment, including maintenance and housekeeping deficiencies in multiple areas.
Failure to report alleged violations of abuse and neglect to the appropriate state agency within required timeframes.
Failure to thoroughly investigate allegations of abuse, including lack of notarized witness statements and record review.
Failure to complete annual comprehensive assessments and significant change assessments within required timeframes.
Failure to develop and finalize baseline care plans within 48 hours of admission and provide a summary to residents or representatives.
Failure to develop and implement comprehensive person-centered care plans addressing restorative nursing, falls, bathing, grooming, and other resident needs.
Failure to provide restorative nursing services as planned for residents with limited range of motion.
Failure to provide adequate supervision and assistive devices to prevent falls, resulting in resident falls with fractures.
Failure to provide necessary services to maintain adequate grooming and personal hygiene, including failure to provide scheduled showers and grooming.
Failure to provide ongoing activities program that meets resident interests and preferences, including failure to assist residents to attend activities.
Failure to provide care and treatment to promote healing of multiple pressure ulcers, including failure to implement ordered wound care treatments.
Failure to provide sufficient mechanical lifts to accommodate timely transfers for residents requiring mechanical lifts.
Failure to provide a safe, functional, and sanitary environment, including broken cabinet doors, cracked floor tiles, and ceiling stains.
Failure to provide sufficient nursing staff to ensure resident safety and care needs were met.
Failure to ensure licensed nurse competency, including medication administration errors where nurse aides were given medications to administer.
Failure to provide annual performance reviews and dementia training for direct care staff.
Failure to monitor resident for side effects of antipsychotic medications and failure of pharmacist to report irregularities related to lack of monitoring.
Report Facts
Residents requiring restorative nursing: 28
Days resident received restorative nursing services: 4
Resident falls: 3
Resident showers received: 1
Resident falls risk score: 17
Resident BIMS score: 9
Resident BIMS score: 14
Resident BIMS score: 3
Resident BIMS score: 15
Resident BIMS score: 8
Resident BIMS score: 15
Resident BIMS score: 3
Resident BIMS score: 10
Resident BIMS score: 14
Resident BIMS score: 10
Resident BIMS score: 9
Resident BIMS score: 10
Resident BIMS score: 14
Resident BIMS score: 9
Resident BIMS score: 10
Resident BIMS score: 14
Resident BIMS score: 3
Resident BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MM | Licensed Nurse | Set-up medications and gave to nurse aides to administer. |
| BB | Licensed Nursing Staff | Responsible for wound care treatments and reported failure to change dressings as ordered. |
| D | Administrative Nursing Staff | Verified restorative nursing program issues and care plan deficiencies. |
| B | Administrative Nursing Staff | Verified lack of restorative nursing program and failure to monitor antipsychotic side effects. |
| A | Administrative Staff | Oversaw activities program and confirmed failure to provide activities. |
| H | Licensed Nursing Staff | Reported staffing shortages and restorative nursing program issues. |
| S | Direct Care Staff | Reported staffing shortages and failure to provide showers. |
| Q | Direct Care Staff | Recalled resident activity preferences and staffing issues. |
| X | Direct Care Staff | Reported lack of restorative nursing training and program. |
| N | Direct Care Staff | Reported restorative nursing program staffing issues. |
| C | Licensed Nursing Staff | Reported resident fall risk and care plan issues. |
| F | Licensed Nursing Staff | Reported resident fall and bed position issues. |
| E | Licensed Nursing Staff | Reported resident fall and bed position issues. |
| J | Direct Care Staff | Reported resident fall risk and care plan issues. |
| M | Direct Care Staff | Reported resident fall risk and care plan issues. |
| U | Direct Care Staff | Reported resident care plan and restorative nursing program issues. |
| GG | Direct Care Staff | Assisted resident transfer with Hoyer lift. |
| HH | Direct Care Staff | Assisted resident transfer with Hoyer lift. |
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Mar 13, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection conducted on March 13, 2019, and related investigations.
Findings
The plan outlines corrective actions taken or planned to address multiple deficiencies including resident dignity, environmental issues, abuse/neglect reporting, care plan updates, wound care, staffing, medication administration, and other compliance areas. The facility commits to ongoing audits and education with results reported to the QAPI committee.
Deficiencies (18)
Concern regarding treatment of residents in a dignified manner.
Environmental deficiencies including repairs and cleaning of furniture, vents, walls, and removal of unlabeled personal items.
Failure in timely reporting and investigation of abuse/neglect/misappropriation.
Care plan reviews and updates not timely or comprehensive.
Significant change of status MDS completion issues.
Baseline care plans not completed within 48 hours after admission.
Comprehensive care plans not reviewed and revised per schedule.
Care plans not updated with resident preferences and ADL care needs.
Activity preferences and care plans not reviewed and updated.
Wound care and treatment assessments incomplete or untimely.
Restorative therapy assessments not updated.
Fall interventions and assistive devices not properly implemented or audited.
Staffing schedules not adequately reviewed or adjusted to meet resident needs.
Medication administration competency and audits lacking.
Nurse aide performance reviews and dementia training incomplete.
AIMS assessments for residents on antipsychotic medications incomplete or improperly reported.
Resident transfer needs and equipment assessments incomplete.
Environmental maintenance issues including broken floor tiles and ceiling stains.
Report Facts
Resident interviews: 5
Resident audits: 5
Audit frequency: 3
Resident discharges reviewed: 5
Staffing review frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chidomukwindidza | Administrator | Administrator named as responsible for re-education and oversight of corrective actions. |
| Janice Vangotten | Modified the Plan of Correction document. | |
| Evelyn Lacey | Added the Plan of Correction document. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 20, 2018
Visit Reason
A revisit survey was conducted on 6/20/18 to verify correction of all previous deficiencies cited on 5/1/18.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 5/23/18, and no new noncompliance was found. The facility is in compliance with all regulations.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 12
Date: May 23, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to achieve substantial compliance by May 23, 2018.
Findings
The plan addresses multiple deficiencies including failure to provide residents with state survey agency contact information, medication administration issues, comprehensive assessments for functional limitations, care plan updates for pressure ulcers and urinary catheters, discharge summaries, activity programming, hospice care coordination, pressure ulcer prevention, medication order accuracy, food service quality and sanitation, infection control, and antibiotic stewardship.
Deficiencies (12)
Failure to provide residents with written information on how to contact the State Survey agency
Failure to provide medication as ordered for Resident #35
Incomplete comprehensive assessments for functional limitations
Care plan updates needed for pressure ulcer and urinary catheter
Incomplete discharge summaries for discharged residents
Lack of ongoing activities for residents
Inadequate coordination of hospice care
Failure to implement effective interventions to prevent worsening pressure ulcers
Failure to ensure all residents receive medication as ordered
Failure to serve palatable food at appetizing temperatures
Failure to store and prepare food under sanitary conditions
Failure to maintain an infection control program to prevent disease transmission
Report Facts
Audit frequency: 3
Resident numbers referenced: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Chidomukwindidza | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added Plan of Correction | |
| Lori Mouak | Modified Plan of Correction | |
| Director of Nursing Services | Director of Nursing Services | Responsible for monitoring infection control program and education |
| Certified Dietary Manager | Certified Dietary Manager | Responsible for food service audits and education |
Inspection Report
Census: 67
Deficiencies: 13
Date: May 1, 2018
Visit Reason
Health Resurvey and investigation of multiple complaints including resident rights, abuse, neglect, medication errors, and infection control.
Complaint Details
The inspection included investigation of complaints #112672, #113634, #116949, #117713, #121609, #122891, #124601.
Findings
The facility was cited for multiple deficiencies including failure to provide required resident notices, failure to report alleged violations, inaccurate assessments, failure to revise care plans, inadequate discharge summary, insufficient activities program, poor quality of care related to pressure ulcers, medication regimen review errors, food temperature and sanitation issues, infection prevention and control failures, and lack of antibiotic stewardship.
Deficiencies (13)
Failure to provide required written information on how to contact the State Survey agency for complaints to residents.
Failure to report alleged violations involving abuse, neglect, and medication errors to the state agency within required timeframes.
Failure to complete accurate comprehensive assessments for residents related to functional limitations and cognition/mood.
Failure to review and revise care plans for pressure ulcers and urinary catheter as needed.
Failure to ensure creation of a discharge summary including recapitulation of resident's stay and treatment.
Failure to provide an ongoing activity program based on resident preferences and needs.
Failure to provide quality care to prevent worsening and development of pressure ulcers including inadequate repositioning and care plan interventions.
Failure to identify medication error and act upon pharmacist recommendations for unnecessary medications.
Failure to serve palatable food at safe and appetizing temperatures for residents receiving room trays.
Failure to store, prepare, and serve food under sanitary conditions including unclean shelving and improper sanitizer storage.
Failure to maintain an infection control program including improper urinary catheter care, unsanitary storage of air mattress pumps, and inadequate sanitization of multi-resident glucometers.
Failure to ensure proper PEG tube care and maintenance following tube feedings to prevent infections.
Failure to ensure compliance with an antibiotic stewardship program including incomplete infection tracking and lack of follow-up on antibiotic use.
Report Facts
Residents sampled: 21
Residents with medication error: 1
Residents with inaccurate assessments: 4
Residents with pressure ulcers reviewed: 2
Residents with antibiotic use reviewed: 12
Temperature of food items: 50
Temperature of food items: 102
Temperature of food items: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Administrative Nursing Staff | Named in medication error finding related to Risperidone administration. |
| Staff A | Administrative Staff | Named in complaint investigation and failure to provide resident complaint contact information. |
| Staff B | Administrative Nursing Staff | Named in antibiotic stewardship and infection control findings. |
| Staff S | Licensed Nursing Staff | Named in medication administration and infection control findings. |
| Staff EE | Dietary Staff | Named in food temperature and sanitation findings. |
| Staff Q | Administrative Staff | Named in activities program deficiency. |
| Staff V | Licensed Nursing Staff | Named in pressure ulcer care and infection control findings. |
| Staff T | Consulting Wound Staff | Named in pressure ulcer care findings. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 7, 2017
Visit Reason
The off-site visit was conducted to verify that the deficiency cited on 10/13/2017 was corrected.
Findings
The deficiency cited on 10/13/2017 was found to be corrected effective October 20, 2017.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 20, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation survey of Diversicare of Chanute.
Complaint Details
This Plan of Correction is linked to Diversicare of Chanute Complaint 101317.
Findings
The plan addresses deficiencies related to oral assessments and dental care for residents, including completion of oral assessments, dental appointments for Resident #1, care plan updates, and staff education on oral care.
Deficiencies (1)
Failure to complete oral assessments and provide dental care as required.
Report Facts
Dates of oral assessments and appointments: Resident #1 oral assessment completed on 2017-09-28; dental appointments on 2017-10-11 and 2017-10-24; all residents' oral assessments completed on 2017-10-13.
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Chidomukwindidza | Administrator | Submitted the Plan of Correction. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 13, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective October 20, 2017.
Deficiencies (1)
Most serious deficiency was an "E" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signer of the report letter. |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Date: Oct 13, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#121726) regarding the facility's failure to provide adequate dental services to residents.
Complaint Details
The complaint investigation (#121726) found the facility failed to provide adequate dental services and assessments for resident #1, including failure to identify dental needs and provide timely dental care.
Findings
The facility failed to ensure that one resident received adequate dental assessment and care, lacked a system to identify residents needing dental services, and did not complete routine oral assessments. The resident had broken lower front teeth with no timely dental intervention, and the facility lacked a dental services policy.
Deficiencies (1)
Failure to provide or obtain routine and emergency dental services to meet the needs of residents, including lack of assessment and care for resident #1's dental condition.
Report Facts
Resident census: 70
Residents sampled: 3
Broken teeth: 4
Date of resident's annual Minimum Data Set: Dec 23, 2016
Date of care plan: Jun 15, 2017
Date of dental progress/treatment/examination: Oct 11, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 28, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety for specific regulatory citations.
Deficiencies (1)
Facility conditions constituted Immediate Jeopardy, Past Non-compliance to resident health or safety for F155, "L", CFR 483.10(c)(6)(8)(g)(12), 483.24(a)(3).
Report Facts
Days to request Informal Dispute Resolution: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter and contact for questions concerning the instructions contained in the letter. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: Jun 28, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#117428) regarding the facility's failure to honor a resident's code status and maintain accurate documentation of code status for multiple residents.
Complaint Details
Complaint investigation #117428 revealed failure to honor resident #1's full code status and failure to maintain accurate code status documentation for 10 residents.
Findings
The facility failed to initiate CPR for a resident who was a full code and found unresponsive without vital signs, placing the resident in immediate jeopardy. Additionally, the facility failed to maintain accurate and accessible code status documentation for 10 of 69 residents, including the resident involved in the incident.
Deficiencies (2)
Failure to honor one resident's full code status by not initiating CPR when found unresponsive without vital signs.
Failure to maintain an accurate system to ensure staff awareness of code status for 10 of 69 residents.
Report Facts
Resident census: 69
Residents with inaccurate code status documentation: 10
Residents affected by failure to honor code status: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | Reported resident was found unresponsive and did not initiate CPR, believing resident was too far gone | |
| Licensed nursing staff D | Verified resident was found unresponsive and CPR was not initiated | |
| Direct care staff E | Reported resident was fine at 10 PM bed-check and later found unresponsive | |
| Direct care staff F | Reported resident was unresponsive and called nurse | |
| Social Services/Activity staff G | Responsible for placement of code status in resident charts, reported possible oversight | |
| Administrative nursing staff B | Reported expectations for initiating CPR and responsibility for code status documentation | |
| Nurse C | Assessed resident and declared resident 'gone', instructed staff to clean resident |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 28, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Complaint Details
This plan of correction is linked to a complaint investigation identified as DVC Chanute complaint dated 06/28/2017.
Findings
The plan addresses past non-compliance issues identified under tags F0000 and F155-L, with no new plan of correction required as these were past non-compliance findings.
Deficiencies (2)
Past non-compliance; no POC required
Past non-compliance; no POC required
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 16, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report indicates that all previously cited deficiencies have been corrected as of the dates noted, with no uncorrected deficiencies remaining.
Deficiencies (1)
Deficiency related to regulations 483.24 and 483.25(k)(l) previously cited under ID Prefix F0309
Report Facts
Date of correction completion: Apr 25, 2017
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 25, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation survey of Diversicare of Chanute.
Findings
The plan addresses a deficiency related to Resident #5's cardiology referral and pacemaker monitoring. It includes corrective actions such as updating the care plan, assessing all residents with pacemakers, educating nursing staff, and auditing pacemaker checks to ensure compliance.
Deficiencies (1)
Failure to ensure Resident #5 received timely cardiology referral and monitoring of pacemakers for residents.
Report Facts
Audit frequency: 4
Audit frequency: 2
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 22, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the previously cited deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of 03/31/2017. No other deficiencies were noted.
Deficiencies (1)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Report Facts
Deficiency correction date: Mar 31, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 20, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be 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 effective April 25, 2017.
Deficiencies (1)
"D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: Apr 20, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#114606) regarding the facility's care and services.
Complaint Details
The complaint investigation #114606 found deficiencies related to inadequate monitoring of a resident with a pacemaker, including lack of physician orders and monitoring system.
Findings
The facility failed to adequately monitor one resident with a pacemaker by not obtaining physician orders for pacemaker checks or implementing a monitoring system. The resident had not had a pacemaker check since admission approximately three years prior, and the facility lacked a policy for monitoring pacemaker function.
Deficiencies (2)
Failure to clarify and/or obtain physician orders related to implementing a monitoring system to maintain and ensure the functioning of a resident's pacemaker.
Lack of a facility policy to instruct staff related to residents with a pacemaker and monitoring for pacemaker functioning.
Report Facts
Census: 69
Residents reviewed: 5
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 30, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a 'D' level deficiency, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
Most serious deficiencies found were at a 'D' level, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Mar 30, 2017
Visit Reason
Investigation of complaint #113696 regarding the facility's failure to provide adequate supervision and assistive devices to prevent resident elopement.
Complaint Details
Investigation of complaint #113696. The complaint was substantiated as the facility failed to prevent elopement of resident #01.
Findings
The facility failed to prevent resident #01, an elopement risk, from exiting the facility without staff knowledge when a vendor staff opened the front door and allowed the resident to leave. The resident was found outside without injury and returned to the facility. The facility updated care plans and trained vendors to prevent recurrence.
Deficiencies (1)
Failure to provide adequate supervision and assistive devices to prevent resident elopement when a vendor staff opened the front door and resident exited without staff knowledge.
Report Facts
Census: 71
Elopement risk residents: 15
Resident BIMS score: 7
Elopement duration: 15
Outside temperature: 76
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 23, 2017
Visit Reason
The plan of correction addresses deficiencies identified in a complaint investigation related to resident elopement risk and facility security procedures.
Complaint Details
Complaint investigation related to resident elopement; family and doctor notified; corrective actions implemented.
Findings
Resident #1 was assisted back into the center without injury after an elopement event. The facility updated care plans, reassessed elopement risks for all residents, educated staff and vendors on elopement prevention, and implemented new signage and audit procedures to ensure compliance.
Deficiencies (1)
Failure to prevent resident elopement and ensure proper supervision by vendors and staff.
Report Facts
Corrective action completion timeframe: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for plan of correction assistance | |
| Chidomukwindidza | Administrator | Submitted plan of correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 29, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report indicates that the previously cited deficiency with regulation 483.10(f)(1)-(3) was corrected and the corrective action was completed by the revisit date.
Deficiencies (1)
Deficiency related to regulation 483.10(f)(1)-(3)
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 22, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 29, 2016.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Dec 22, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#105926) regarding the facility's failure to provide a resident with menu preference choices.
Complaint Details
The complaint investigation #105926 found that the facility did not consistently provide the resident with their requested menu choice of rice for breakfast, sometimes substituting cereal due to kitchen limitations. The resident's family expressed concerns about the dietary issues.
Findings
The facility failed to provide 1 of 3 sampled residents with a menu preference choice for breakfast. Despite the resident's consistent request for rice, staff sometimes served cereal instead due to unavailability or preparation issues. The facility's policy on alternate foods was not adequately followed.
Deficiencies (1)
Failure to provide resident #1 with a menu preference choice for breakfast.
Report Facts
Census: 66
Sampled residents: 3
Deficiency count: 1
BIMS score: 13
Date of resident admission: Dec 28, 2012
Date of physician orders: Nov 30, 2016
Date of annual MDS: Sep 16, 2016
Date of care plan: Sep 16, 2016
Date of progress notes: Sep 21, 2016
Date of menu ticket: Dec 11, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 22, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as DVC Chanute complaint 12222016.
Findings
The facility failed to ensure that all residents received their preferred breakfast choice, specifically Resident #1 who did not receive shredded wheat as requested. The dietary team was re-educated and audits were planned to ensure compliance.
Deficiencies (1)
Failure to ensure all residents receive a preference choice for breakfast.
Report Facts
Plan of Correction completion date: Dec 29, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Chidomukwindidza | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Aug 12, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction completed and documented under the respective regulation numbers.
Deficiencies (8)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(g)-(j)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.60(b), (d), (e)
Deficiency related to regulation 483.65
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Aug 12, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to address and ensure compliance with regulations.
Findings
The Plan of Correction details multiple deficiencies related to environmental issues, resident assessments, medication documentation, vehicle maintenance, cleaning protocols, and medication storage, with corrective actions including staff education, audits, repairs, and ongoing monitoring through the QAPI committee.
Deficiencies (8)
Environmental items discussed during the exit have been addressed with maintenance and housekeeping staff; showers to be refurbished and floor repairs underway.
Resident #27's records reviewed and updated; RNAC re-educated on accurate MDS and significant change assessment.
Alternate vehicle arranged for resident transport until center bus repaired; temperature audits in van scheduled.
Medications for residents #35, #53, and #79 updated to reflect proper diagnosis; staff educated on documentation.
Areas identified during survey cleaned; dietary staff in-serviced on cleaning and sanitizing equipment.
Resident #10, #53, and #81 reviewed and Drug Regimen Review addressed; medical records educated on timely return of DRR.
Medication carts and crash carts checked; expired medications removed and carts cleaned; nurses educated on these procedures.
Housekeeping staff reeducated on appropriate cleansing of resident rooms and use of Virex to prevent infection spread.
Report Facts
Audit frequency: 5
Audit frequency: 4
Audit frequency: 3
Complete date: Aug 12, 2016
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 8
Date: Jul 22, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #102138 and #102770 to assess compliance with regulatory requirements.
Complaint Details
The inspection included complaint investigations #102138 and #102770.
Findings
The facility failed to maintain sanitary housekeeping and maintenance services, complete accurate resident assessments, provide adequate care and services including medication management, maintain sanitary food storage and preparation, ensure timely pharmacist medication reviews, and uphold infection control practices.
Deficiencies (8)
Failed to provide housekeeping and maintenance services to maintain a sanitary interior, including stained carpets, broken tiles, peeling paint, dirty floors, and damaged equipment.
Failed to complete an accurate comprehensive assessment for a resident related to hospice care.
Facility van lacked adequate air conditioning for transporting residents in wheelchairs, causing discomfort and heat exposure.
Failed to ensure residents' drug regimens were free from unnecessary drugs, including lack of diagnoses for medications and delayed pharmacist recommendation follow-up.
Failed to store, distribute, and serve food under sanitary conditions, including grime buildup and unlabeled food items.
Failed to timely act upon pharmacist medication recommendations for multiple residents, risking adverse effects and unnecessary medication use.
Failed to adequately monitor and remove expired medications from medication carts and crash cart, including multiple expired drugs and dusty equipment.
Failed to maintain an effective infection control program, including improper cleaning of toilets and surfaces, risking spread of infection.
Report Facts
Residents in wheelchairs transported in van: 38
Residents sampled for medication review: 19
Expired medications found: 8
Pharmacist recommendation follow-up delay: 52
Pharmacist recommendation follow-up delay: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Staff E | Licensed Nursing Staff | Mentioned in relation to medication storage and expired medication observations. |
| Licensed Nursing Staff G | Licensed Nursing Staff | Mentioned in relation to medication order entry and diagnosis follow-up. |
| Housekeeping Staff P | Housekeeping Staff | Observed performing cleaning with improper disinfectant wet time and incomplete toilet cleaning. |
| Housekeeping Staff J | Housekeeping Staff | Provided information on cleaning practices and schedules. |
| Administrative Nursing Staff B | Administrative Nursing Staff | Discussed pharmacist recommendation follow-up and medication expiration monitoring. |
| Administrative Nursing Staff G | Administrative Nursing Staff | Described process for sending and tracking pharmacist recommendations. |
| Consultant Staff M | Consultant Staff | Checked medication carts and medication room for expired medications. |
| Licensed Nursing Staff O | Licensed Nursing Staff | Observed medication storage and identified expired medications. |
Inspection Report
Deficiencies: 1
Date: Jul 22, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, 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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the letter and referenced as contact for questions. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 3, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that the deficiencies previously cited under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h) were corrected as of 04/08/2016.
Deficiencies (2)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.25(h)
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 1, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found at 'F' level indicating no harm with potential for more than minimal harm but not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jul 1, 2016
Provider agreement termination date: Oct 1, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and is responsible for licensure certification and enforcement |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 25, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was given.
Deficiencies (1)
Deficiencies found at a level of actual harm that is not immediate jeopardy
Report Facts
Months until termination recommendation: 6
Denial of payment effective date: Apr 14, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as contact for questions concerning the instructions contained in the letter. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 2
Date: Mar 25, 2016
Visit Reason
The inspection was conducted based on complaint investigations #97696 and #97887, focusing on allegations of neglect and failure to investigate and report incidents properly.
Complaint Details
The visit was triggered by complaint investigations #97696 and #97887 concerning neglect and failure to report incidents properly.
Findings
The facility failed to thoroughly investigate and report possible neglect of two residents who sustained fractured hips after falls. The facility lacked appropriate fall prevention interventions, failed to implement adequate supervision and assistive devices, and did not have a policy for investigating and reporting falls and potential neglect. Staff were unaware of the 'Call before you Fall' program and did not consistently follow care plans or post-fall interventions.
Deficiencies (2)
Failure to thoroughly investigate and report possible neglect of residents who fell and sustained fractured hips.
Failure to provide appropriate interventions and supervision to prevent falls, including lack of effective fall prevention program and inconsistent use of assistive devices.
Report Facts
Resident census: 75
Residents reviewed: 9
BIMS scores: 11
BIMS scores: 9
BIMS scores: 7
BIMS scores: 13
BIMS scores: 15
Falls: 3
Blood pressure readings: 140
Blood pressure readings: 77
Blood pressure readings: 134
Blood pressure readings: 72
Blood pressure readings: 94
Blood pressure readings: 62
Blood pressure readings: 142
Blood pressure readings: 74
Blood pressure readings: 118
Blood pressure readings: 72
Blood pressure readings: 90
Blood pressure readings: 58
Pain rating: 9
Pain rating: 8
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 11, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the previously cited deficiency under regulation 483.60(a),(b) was corrected as of the revisit date.
Deficiencies (1)
Deficiency under regulation 483.60(a),(b) previously cited and corrected
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 24, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be 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, resulting in a finding of substantial compliance effective March 11, 2016.
Deficiencies (1)
Most serious deficiency was a D level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to survey findings and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Feb 24, 2016
Visit Reason
The inspection was conducted as an investigation of complaint #97169 regarding the facility's pharmaceutical services.
Complaint Details
Investigation of complaint #97169 regarding failure to provide chemotherapy medication as ordered. The complaint was substantiated by findings of delayed medication administration.
Findings
The facility failed to provide chemotherapy medication (Xtandi) as ordered for one skilled care resident, resulting in a 21-day delay in administration due to cost and procurement issues.
Deficiencies (1)
Failed to provide chemotherapy medication as ordered for one skilled care resident.
Report Facts
Resident census: 72
Skilled care residents with orders: 10
Days medication delayed: 21
Medication cost increase: 8000
Previous medication cost: 180
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 17, 2016
Visit Reason
This plan of correction addresses deficiencies cited during a survey related to medication administration, specifically concerning a resident who received chemotherapy medication on February 17, 2016.
Findings
The facility identified a medication administration issue involving Resident #1 receiving chemotherapy medication. An audit was conducted to identify other residents potentially affected, and corrective actions including medication review processes were implemented to ensure compliance.
Deficiencies (1)
Resident #1 received chemotherapy medication on February 17, 2016, with potential for other residents to be affected due to missing medications.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Date: Jan 29, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on allegations related to elopement risks and failure to report an elopement incident.
Complaint Details
The complaint investigations #96423, #96590, and #96630 focused on allegations of failure to report elopement and inadequate supervision of residents at risk of elopement. The facility was found to have failed to report an elopement incident and failed to provide adequate supervision to prevent the elopement of one resident.
Findings
The facility failed to report an elopement of a resident to the state agency as required and failed to provide adequate supervision and assistive devices to prevent the elopement of one resident. The resident left the facility without staff knowledge, traveled approximately 20 miles to their home, and returned without staff awareness until family notified the facility.
Deficiencies (2)
Failure to report an elopement from the facility without staff knowledge to the state agency as required.
Failure to provide adequate supervision and assistive devices to prevent the elopement of a resident.
Report Facts
Census: 73
Elopement risks identified: 13
Residents sampled for review: 3
Distance walked by resident: 20
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 29, 2016
Visit Reason
This plan of correction is submitted in response to deficiencies cited during a complaint investigation survey conducted at Diversicare of Chanute.
Complaint Details
This plan of correction is related to a complaint investigation at Diversicare of Chanute, complaint ID 01292016.
Findings
The plan addresses deficiencies related to elopement risk, including updating care plans, educating staff and residents, changing door codes, and reporting elopements to the State Survey and Certification Agency.
Deficiencies (2)
Failure to properly notify the designated State agency of an elopement from the facility and inadequate care plan updates for residents at risk of elopement.
Inadequate assessment and management of residents at risk for elopement, including failure to conduct elopement risk assessments on admission and incomplete staff education.
Report Facts
Deficiency completion date: Feb 25, 2016
Resident discharge date: Jan 25, 2016
Door code change date: Jan 29, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Randall Alsup | Administrator | Named as submitting administrator and responsible for education and oversight in plan of correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 11, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiency identified under regulation 483.25(h) was corrected as of 12/11/2015.
Deficiencies (1)
Deficiency under regulation 483.25(h)
Report Facts
Deficiency correction date: Dec 11, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 25, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be 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.
Deficiencies (1)
Most serious deficiency found was a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: Nov 25, 2015
Visit Reason
The inspection was conducted as an investigation of complaint #93721 regarding the facility's failure to provide adequate supervision and assistive devices to prevent falls.
Complaint Details
The complaint investigation found that the facility did not provide adequate supervision or a working personal alarm for resident #01, who fell from a wheelchair and sustained injuries. The resident's personal alarm failed to sound at the time of the fall.
Findings
The facility failed to provide adequate supervision and a working personal alarm to prevent a resident from falling, resulting in the resident sustaining an abrasion and swelling. The resident was at high risk for falls and totally dependent on staff for transfers and mobility.
Deficiencies (1)
Failure to provide adequate supervision and assistive devices to prevent falls for one resident.
Report Facts
Resident census: 73
Sampled residents with falls: 3
Resident falls: 1
Medication dosage: 500
Medication dosage: 250
Date of resident admission: Jan 19, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff B | Acknowledged leaving resident unattended leading to fall | |
| licensed nursing staff A | Completed post fall assessment and recommended interventions |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 23, 2015
Visit Reason
This post-certification revisit was conducted to verify correction of previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that the previously cited deficiency with regulation number 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 22, 2015
Visit Reason
The revisit was conducted on September 22, 2015, following an Abbreviated survey on August 5, 2015, to verify that the facility had achieved and maintained compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.
Findings
The facility was found not to be in substantial compliance with Federal requirements, resulting in enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective November 5, 2015, which will remain until compliance is achieved or the provider agreement is terminated.
Report Facts
Denial of payment effective date: Nov 5, 2015
Termination recommendation date: Feb 5, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Randall Alsup | Administrator | Named as facility administrator |
| Mary Jane Kennedy | LBSW, Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 22, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited in the prior survey were corrected as of the revisit date, with corrections completed on 09/22/2015 for multiple regulatory requirements.
Report Facts
Correction completion date: Sep 22, 2015
Prior survey date: Aug 5, 2015
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Sep 22, 2015
Visit Reason
The inspection was conducted as a non-compliance revisit for multiple prior complaint investigations and current complaint investigations related to resident safety and supervision.
Complaint Details
The visit was a non-compliance revisit for complaint investigations #89255, 89062, 88518, 87562 and current complaint investigations #91502 and 89938. The resident eloped on 9/7/15 and 9/10/15 despite being identified as at risk and under 15-minute checks, which were inconsistently performed and documented.
Findings
The facility failed to provide adequate supervision to prevent elopement for one resident who left the building without staff knowledge twice within three days. The resident was at risk for wandering and elopement, had a history of removing a wanderguard bracelet, and staff failed to consistently perform required 15-minute checks. The facility's care plan and supervision practices were inadequate to prevent the incidents.
Deficiencies (1)
Failure to provide adequate supervision to prevent elopement for a resident who left the building without staff knowledge twice in three days.
Report Facts
Resident census: 72
Residents sampled: 8
Residents reviewed for elopement: 3
Dates of elopement incidents: Resident eloped on 2015-09-07 and 2015-09-10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Noted resident walked past without wanderguard bracelet and involved in supervision issues | |
| Assistant Director of Nursing (ADON) | Assisted resident with wanderguard bracelet and involved in supervision | |
| Staff E | Licensed Nursing Staff | Reported resident was outside walking alone and discussed 15-minute checks |
| Staff B | Administrative Nursing Staff | Reported resident at risk for elopement and issues with 15-minute checks documentation |
| Direct Care Staff C | Direct Care Staff | Reported resident was at risk for elopement and was on 15-minute visual checks before elopement |
| Direct Care Staff D | Direct Care Staff | Reported resident was an elopement risk and knew door code |
| Direct Care Staff F | Direct Care Staff | Reported resident had always been at risk for elopement but did not wear wanderguard bracelet |
| Therapy Staff H | Therapy Staff | Reported seeing resident outside walking without assistance |
| Companion G | Resident Companion | Provided companionship and reported resident had door code written on paper |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 22, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at Diversicare of Chanute.
Complaint Details
This Plan of Correction is related to a complaint investigation survey (Diversicare of Chanute 1st Revisit 092215 Complaint).
Findings
The plan outlines corrective actions including updating care plans for patient #2 with one-on-one coverage due to wandering and elopement risk, replacing door alarms, conducting elopement assessments for all residents, staff education on elopement guidelines, and performing elopement drills to ensure compliance.
Deficiencies (1)
Failure to properly care plan and implement interventions for patient #2 related to wandering and elopement risk.
Report Facts
Date of elopement assessment for patient #2: Sep 10, 2015
Date door alarms changed: Sep 14, 2015
Date of staff education on elopement guidelines: Sep 14, 2015
Date elopement drills performed: Sep 13, 2015
Date patient #2 moved to Alzheimer’s unit: Sep 28, 2015
Substantial compliance target date: Sep 17, 2015
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Sep 4, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint survey conducted at Diversicare Chanute.
Findings
The Plan of Correction outlines multiple corrective actions including re-education of nursing staff on vital sign parameters, admission care plans, skin care documentation, hygiene and grooming policies, hydration expectations, medication delivery, and monitoring procedures to ensure compliance and resident care standards are met.
Deficiencies (7)
Re-education on Vital Sign Parameters and notification to physicians regarding abnormal vital signs.
Audit and completion of Initial Admission Care Plans for new residents.
Proper documentation of bruises, rashes, and skin issues in the wound module of the electronic medical record.
Hygiene and grooming expectations and monitoring of shower completion.
Hydration policy education and monitoring, including provision of fluids and hydration stations.
Modification of computer system to alert nurses when vital sign parameters are out of range.
Monitoring and ensuring timely medication delivery and faxing of prescriptions.
Report Facts
Complete Date: Sep 4, 2015
Audit Date: Aug 6, 2015
Education Date: Jul 30, 2015
In-service Date: Aug 19, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beth Shepard | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 8
Date: Aug 5, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers 89255, 89062, 88518, and 87562.
Complaint Details
The inspection was conducted as a complaint investigation based on complaint investigation numbers 89255, 89062, 88518, and 87562.
Findings
The facility failed to report significant changes in residents' conditions, develop temporary care plans, provide adequate care and services including hygiene and hydration, monitor skin issues, administer medications timely, and maintain sufficient staffing to meet residents' needs.
Deficiencies (8)
Failed to notify physician of significant change in condition for resident #1 with low blood pressure while continuing antihypertensive medication.
Failed to develop temporary care plans for residents #1 and #3 on admission.
Failed to identify and monitor skin issues including rash, bruises, and intravenous infiltrate for residents #1, #3, and #4.
Failed to provide adequate ADL care including hygiene, grooming, and oral care for residents #3 and #4.
Failed to provide sufficient fluid intake to maintain hydration for residents #1, #3, and #4, resulting in dehydration and hospitalization for resident #1.
Failed to monitor medications adequately for resident #1 who received antihypertensive medications without parameters for administration and had low blood pressures.
Failed to provide sufficient nursing staff to maintain the highest practicable physical, mental, and psychosocial well-being of residents, resulting in numerous missed scheduled showers/baths.
Failed to have medications available on admission and failed to administer medications timely for residents #1 and #3.
Report Facts
Census: 73
Scheduled showers/baths missed: 74
Scheduled showers/baths missed: 86
Scheduled showers/baths missed: 103
Scheduled showers/baths missed: 132
Scheduled showers/baths missed: 63
Fluid intake average: 217
Fluid intake average: 722
Fluid intake average: 740
Medication delay: 11
Medication delay: 3.5
Medication delay: 4
Medication delay: 2
Medication delay: 4
Medication delay: 3.78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff B | Reported on medication monitoring, hydration, and staffing issues. | |
| Licensed Nursing Staff F | Reviewed blood pressure documentation and medication administration. | |
| Licensed Nursing Staff D | Reported on medication orders and hydration care. | |
| Direct Care Staff J | Reported on hydration and shower care issues. | |
| Administrative Staff A | Present during staffing interview. | |
| Licensed Nursing Staff E | Reported on shower care issues. | |
| Direct Care Staff K | Reported on hydration and shower care issues. | |
| Direct Care Staff H | Reported on hydration and shower care issues. | |
| Licensed Nursing Staff G | Provided care to resident #3 and described condition. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 22, 2015
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that deficiencies identified in prior surveys have been corrected as of the revisit date, with corrections completed for items F0242, F0315, and F0327.
Deficiencies (3)
Deficiency identified under regulation 483.15(b)
Deficiency identified under regulation 483.25(d)
Deficiency identified under regulation 483.25(j)
Report Facts
Deficiencies corrected: 3
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 23, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective April 22, 2015.
Deficiencies (1)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator for KDADS. |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Date: Mar 23, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint investigations #83730 and #83817 to assess compliance with resident care and facility regulations.
Complaint Details
The inspection included complaint investigations #83730 and #83817. The findings substantiated failures in bathing, incontinence care, and hydration assistance.
Findings
The facility failed to provide one resident with bathing according to their preference, failed to provide proper incontinence care to prevent urinary tract infections for another resident, and failed to provide adequate assistance for hydration to a resident at risk for dehydration.
Deficiencies (3)
Failed to provide one resident (#54) with bathing 3 times a week according to the resident's individual preference.
Failed to provide proper incontinence care for one resident (#12) to prevent urinary tract infections, including failure to check and change every 2 hours and improper perineal care.
Failed to provide adequate assistance for hydration to one resident (#23) reviewed for dehydration, including improper positioning of water pitcher and inadequate monitoring of fluid intake.
Report Facts
Residents reviewed: 18
Resident census: 63
Bathing frequency: 3
Incontinence check frequency: 2
Fluid intake range: 100
Fluid intake range: 600
Ensure can volume: 237
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 11, 2015
Visit Reason
This report documents a revisit inspection to verify that previously identified deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit inspection confirmed that the previously reported deficiency identified by regulation 28-39-160 with prefix code S0770 was corrected as of 03/11/2015.
Deficiencies (1)
Deficiency previously reported under regulation 28-39-160 with prefix code S0770
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Date: Feb 20, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#84102) and a partial extended survey related to the facility's provision of adult day care services and supervision of residents.
Complaint Details
Complaint investigation #84102 focused on the incident where a cognitively impaired resident exited the facility without staff knowledge and was found lying in a ditch two blocks away on a cold night. The investigation found failures in supervision, assessment, and communication with family.
Findings
The facility failed to provide adequate supervision to prevent a cognitively impaired resident from leaving the facility unnoticed, resulting in the resident being found lying in a ditch approximately two blocks away on a cold night. The facility also lacked a day care policy and failed to complete an assessment for the cognitively impaired resident upon admission to day care.
Deficiencies (3)
Failure to provide adequate supervision to prevent resident from leaving the facility without staff knowledge, resulting in immediate jeopardy.
Lack of written policies and procedures for provision of adult day care services.
Failure to complete an assessment for the cognitively impaired day care resident on admission to day care to ensure identification of individualized care needs.
Report Facts
Resident census: 67
Residents at risk for elopement: 10
Day care residents: 1
Temperature: 28
Wind chill: 19
Vital signs - blood pressure: 132/101
Vital signs - pulse: 90
Vital signs - respirations: 16
Vital signs - SpO2: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff C | Conducted internal investigation of the incident | |
| Licensed nursing staff G | Notified family of resident leaving facility, failed to assess resident upon return | |
| Direct care staff H | Assisted resident to put coat on and observed resident in lobby | |
| Direct care staff I | Observed resident in lobby after evening meal | |
| Administrative staff A | Provided information about staff responsibility and resident attendance | |
| Officer J | Police officer who found resident in ditch and returned resident to facility | |
| Maintenance staff M | Checked exit door alarms with wander guard system | |
| Licensed nursing staff K | Asked about resident's presence when EMS was bringing resident back |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 19, 2015
Visit Reason
This Plan of Correction is submitted in response to deficiencies cited during a complaint survey at Diversicare Chanute.
Findings
The facility will no longer provide Daycare Services to resident #1 or others requesting the service. Staff received education on elopement policy and daycare service discontinuation. New elopement assessments were conducted on all current residents. Door alarm key codes were changed and door checks will be conducted daily with concerns reported promptly. Compliance is expected by 02/28/2015.
Deficiencies (1)
Offering Daycare Services to resident #1 and others despite policy concerns.
Report Facts
Date of staff education: Feb 19, 2015
Plan of Correction completion date: Feb 28, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beth Shepard | Administrator | Administrator conducted staff education and submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 14, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiency found was an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payments effective date: Nov 14, 2014
Provider agreement termination date: Feb 14, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Shepard | Administrator | Named as facility administrator in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Joe Ewert | Commissioner | Mentioned in carbon copy (c:). |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 10, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date, January 10, 2014.
Report Facts
Deficiencies corrected: 7
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 7
Date: Dec 11, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #69055 to investigate allegations of abuse, neglect, and compliance with regulatory requirements.
Complaint Details
The visit was complaint-related as it included a complaint investigation #69055 focusing on allegations of abuse and neglect, and other regulatory compliance issues.
Findings
The facility failed to thoroughly investigate and report incidents of alleged abuse and neglect, maintain a sanitary and safe environment, properly update care plans for residents with skin conditions and pressure ulcers, provide appropriate care to prevent urinary tract infections, ensure safe water temperatures, and maintain infection control procedures.
Deficiencies (7)
Failed to thoroughly investigate and report 4 incidents of alleged abuse and neglect involving residents, including incomplete investigations and failure to report to the state agency.
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, including multiple issues with resident bathrooms and rooms.
Failed to review and revise care plans for residents with skin conditions and pressure ulcers to ensure proper identification and treatment.
Failed to provide necessary care and services to identify and monitor bruising and skin issues for residents, including failure to notify physicians and update care plans.
Failed to provide appropriate care to prevent urinary tract infections and failed to use anchoring devices for indwelling catheters to prevent urethral trauma.
Failed to ensure a safe environment by allowing water temperatures in resident bathrooms to exceed 120 degrees Fahrenheit, posing a burn risk to cognitively impaired, self-mobile residents.
Failed to maintain infection control procedures to prevent cross contamination, including improper cleaning and disinfection of isolation rooms for residents with C-Diff, and failure to check mop water dilution and use appropriate disinfectants.
Report Facts
Incidents of alleged abuse and neglect: 4
Resident census: 65
Water temperature: 133.1
Water temperature: 124.8
Bruise size: 12.6
Bruise size: 8.4
Pressure ulcer size: 9
Pressure ulcer size: 8
Pressure ulcer size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Provided information on abuse investigations and water temperature monitoring. | |
| Licensed nurse H | Reported on skin assessments and care plan updates for residents with skin issues. | |
| Licensed administrative nurse B | Reported on documentation and investigation procedures for bruises and skin issues. | |
| Maintenance staff E | Reported on water temperature adjustments and monitoring. | |
| Housekeeping staff P | Described cleaning procedures and use of disinfectants in isolation rooms. | |
| Housekeeping staff Q | Described cleaning procedures and use of disinfectants in isolation rooms. | |
| Licensed nursing staff I | Described expectations for CNA reporting of skin issues and bruise documentation. |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Sep 28, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited with various regulation numbers were corrected as of the revisit date, with corrections completed on 09/28/2012.
Deficiencies (9)
Deficiency identified under regulation 483.10(e), 483.75(l)(4)
Deficiency identified under regulation 483.15(f)(1)
Deficiency identified under regulation 483.15(h)(2)
Deficiency identified under regulation 483.20(b)(1)
Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.25
Deficiency identified under regulation 483.35(c)
Deficiency identified under regulation 483.55(a)
Deficiency identified under regulation 483.70(h)
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Sep 28, 2012
Visit Reason
This Plan of Correction document is submitted in response to deficiencies cited during a prior survey to outline corrective actions the facility will implement to achieve compliance with state and federal regulations.
Findings
The facility identified multiple deficiencies including issues with patient dignity and rights, individualized care planning, environmental repairs, oral health assessments, dietary menu compliance, and sanitation. The plan details corrective actions such as staff education, environmental repairs, monitoring, and quality assurance committee oversight to ensure substantial compliance by September 28, 2012.
Deficiencies (6)
Failure to ensure dignity and patient rights; staff education provided.
Inadequate individualized activity programming and care planning for patient #49.
Environmental and maintenance deficiencies including gaps in molding, wall cracks, rusted toilet riser, odors, and bathroom repairs.
Lack of oral health assessments and monitoring for patients, including patient #28.
Failure to ensure menus meet resident needs and are prepared in advance; dietary staff re-education planned.
Unsafe, unsanitary, or uncomfortable environment issues including kitchen cleanliness and maintenance concerns.
Report Facts
Deficiencies cited: 7
Compliance deadline: Sep 28, 2012
Staff in-service dates: Sep 25, 2012
Oral health assessment start date: Sep 17, 2012
Dietary staff re-education completion date: Sep 14, 2012
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 9
Date: Aug 29, 2012
Visit Reason
The inspection was a health resurvey of Chanute Healthcare Center to assess compliance with federal regulations related to resident care, environment, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide resident privacy during care, inadequate activities programming, poor housekeeping and maintenance, incomplete comprehensive assessments, failure to revise care plans for positioning, inadequate dental care and services, failure to provide appropriate positioning devices, failure to follow pureed diet menus, and unsanitary kitchen conditions.
Deficiencies (9)
Failure to provide privacy for one resident during personal care with open doors and no curtains.
Failure to provide meaningful activities for one resident in accordance with assessed interests.
Failure to provide necessary housekeeping and maintenance services resulting in damaged walls, rust, odors, and unclean conditions in resident areas.
Failure to complete a comprehensive assessment of a resident's dental status.
Failure to review and revise the plan of care to ensure proper positioning to maintain good body alignment for a resident with contractures.
Failure to provide necessary care and services to maintain highest practicable well-being related to positioning for one resident.
Failure to follow the preplanned menu for residents receiving pureed diets; pureed cake was not prepared as planned.
Failure to assist a resident in obtaining routine and emergency dental care; dental assessments incomplete and dental problems not addressed.
Failure to maintain a clean and sanitary environment in the kitchen including dirty floors, standing water in sink, holes in walls, and missing base molding.
Report Facts
Residents reviewed: 23
Residents on pureed diets: 6
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Mentioned in relation to providing oral care and privacy failure | |
| Staff P | Mentioned in relation to activities and radio use | |
| Staff L | Restorative staff | Interviewed about resident positioning and activities |
| Staff O | Restorative staff | Interviewed about resident positioning and passive range of motion |
| Staff E | Activity staff | Interviewed about resident attendance at religious services |
| Staff I | Licensed administrative staff | Interviewed about dental assessment and care plan |
| Staff D | Dietary staff | Interviewed about pureed diet preparation and kitchen cleaning |
| Staff F | Social service staff | Interviewed about dental coverage and appointments |
| Staff T | Interviewed about resident cooperation with oral care | |
| Staff U | Interviewed about oral care frequency and resident cooperation | |
| Staff V | Observed providing oral care | |
| Staff W | Dietary staff (night shift) | Interviewed about kitchen cleaning schedule |
| Staff B | Licensed administrative staff | Interviewed about positioning devices and muscle rigidity |
| Consulting staff X | Interviewed about positioning devices |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N067004 POC T1ZI11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint survey at Diversicare of Chanute.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey. Resident #01 was discharged prior to the plan submission. The facility will assess all new admits for accident risks and educate staff on proper alarm use and monitoring.
Findings
The facility identified issues related to the use and monitoring of personal alarms for residents, including failure to ensure alarms were working properly and leaving residents unattended when alarms were not functioning.
Deficiencies (1)
Failure to ensure personal alarms were working properly and not leaving residents alone when alarms were not functioning.
Report Facts
Date of resident discharge: Nov 1, 2015
Date alarms were checked: Nov 25, 2015
Plan completion date: Dec 11, 2015
Monitoring period: 3
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N067004 POC UH4211
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey related to DVC Chanute complaint dated 03/25/2016.
Complaint Details
This Plan of Correction is in response to a complaint investigation triggered by DVC Chanute complaint dated 03/25/2016.
Findings
The facility identified deficiencies related to resident care plans, fall interventions, and reporting of injuries of unknown origin. The Plan of Correction outlines actions including reassessment of care plans, staff education on abuse/neglect policies and fall interventions, timely reporting to KDADS, and ongoing review through Quality Assurance meetings to prevent recurrence.
Deficiencies (2)
Failure to properly reassess and intervene in resident care plans related to falls and injuries of unknown origin.
Inadequate staff education and follow-up on fall interventions and post-fall assessments.
Report Facts
Deficiency completion date: Apr 8, 2016
Resident expiration date: Feb 26, 2016
Care plan reassessment date: Mar 28, 2016
Reporting timeframe: 24
Reporting timeframe: 5
QAPI review timeframe: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Randall Alsup | Administrator | Administrator submitting the Plan of Correction and responsible for staff education and reporting |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Director of Nursing Services | Responsible for reassessing care plans and educating nursing staff |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N067004 POC BT3T11
Visit Reason
This document is a Plan of Correction submitted by Diversicare Chanute in response to deficiencies cited during a prior survey.
Findings
The facility outlines corrective actions to address deficiencies related to care plan updates, personal care guidelines, hydration risk factors, and staff training to ensure compliance with patient preferences and care standards.
Deficiencies (3)
Care plan for patient #54 was updated to reflect patient preferences and showers will be provided according to preferences.
Mandatory in-service training for licensed staff and caregivers on Perineal Care Guidelines, cleaning of personal equipment, and patient-centered care plans.
Hydration risk addressed by attaching a water pocket to resident #23's side rail and providing a smaller water container; staff training on hydration risk factors.
Report Facts
Deficiencies cited: 3
Completion date: Apr 22, 2015
Monitoring report date: Apr 29, 2015
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N067004 POC OCYI11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies.
Findings
The plan indicates that the deficiencies identified (F0000 and F689-G) were past noncompliance issues for which no plan of correction was required.
Deficiencies (2)
Past noncompliance: no plan of correction required.
Past noncompliance: no plan of correction required.
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