Diversicare of Chanute

Inspectors wroteThe facility identified a census of 57 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 received the necessary care, including his personalized physician ordered medication regimen, to alleviate terminal agitation and promote comfort as intended by the hospice provider resulting in increased anxiety/agitation, a fall with an injury and low back pain.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff immediately reported an incident of resident-to-resident abuse allegation to the Administrator and further failed to report the incident to the State Agency (SA).

Inspectors wroteThe facility reported a census of 47 residents; the sample included 15 residents. Based on interviews, record review and observation, the facility failed to ensure a safe, clean home-like environment in the resident's rooms and facility common areas.

Inspectors wroteThe facility reported a census of 47 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure informed consent including purpose, risks versus benefits, and expected therapeutic benefits for the use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), anxiolytic (medication used to treat symptoms of anxiety) and other psychotropic medications (drugs that affect the brain and nervous system to treat mental illnesses)) for one resident, Resident (R)3.

Inspectors wroteThe facility reported a census of 47 residents; the sample included 15 residents with one resident reviewed for activities of daily living (ADLS). Based on observation, interview, and record review, the facility failed to provide nail care for the one sampled resident, Resident (R)5.

Inspectors wroteThe facility reported a census of 47 residents. Based on observation, record review and interview, the facility failed to display accurate, and identifiable staffing information, on a daily basis, for the 47 residents who resided in the facility.- Review of the facility's Daily Staffing sheets, 08/22/25 through 09/21/25, revealed that the actual hours worked per shift had not been completed on the daily staffing sheets. On 09/22/25 at 12:41 PM, Administrative Nurse D confirmed the Daily Staffing sheets lacked the actual hours worked per shift. The facility did not provide a policy.

Inspectors wroteThe facility reported a census of 44 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to provide food that was nutritionally balanced, palatable, attractive, and at safe appetizing temperatures. This placed the residents at risk for inadequate nutrition and decreased quality of life.

Inspectors wroteThe facility reported a census of 44 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to provide the residents of the facility with reasonable access to receive mail.

Inspectors wroteThe facility reported a census of 46 residents with four residents selected for review, including three residents reviewed for skin conditions. Based on observation, interview, and record review, the facility failed to ensure one of the three residents, Resident (R)1, had clean and dry dressings to his lower extremities. On 06/17/24, at an appointment, Consultant Staff GG discovered two maggots on R1's right lower extremity while removing urine and fluid-soaked dressings due to weeping from his right lower extremity. The dressings removed were dated 06/13/24, four days prior, when Consultant Staff GG applied the lymphedema wraps (compression wraps used to try and reduce swelling caused by accumulation of lymph). R1 reported concerns about his wraps to Licensed Nurse (LN) I on 06/16/24 between 10:00 PM to 11:00 PM, and LN I told R1 his wound appointment was scheduled for the next morning. [...]

Inspectors wroteThe facility reported a census of 46 residents with four residents selected for review including three residents reviewed for following physician wound care orders. Based on observation, interview, and record review, the facility failed to ensure one of the residents, Resident (R)4, had the appropriate wound treatment provided.

Inspectors wroteThe facility reported a census 46 with four residents selected for review including three residents reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to monitor bowel functioning for one Resident (R)3 for constipation (difficulty passing stools) and contact the physician for orders to treat the constipation.

Inspectors wroteThe facility reported a census of 46 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program with failure to perform appropriate hand hygiene and a clean dressing change procedure on 06/24/24, and to ensure Resident (R)1 had clean and dry dressings to his lower extremities.

Inspectors wroteThe facility reported a census of 46 residents. Based on observation, interview, and record review, the facility failed to maintain an effective pest control program. On 06/17/24, Resident (R)1 had an appointment where Consultant Staff GG discovered two maggots on R1's right lower extremity while removing urine and fluid-soaked dressings due to weeping from his right lower extremity.

Inspectors wroteThe facility reported a census of 49 residents with five residents reviewed including three residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to administer the physician ordered amount of oxygen to Resident (R)5 and failed to ensure R1's oxygen tank did not run empty and/or was delivering oxygen as prescribed by the physician.

Inspectors wroteThe facility reported a census of 49 residents with five residents selected for review, including one reviewed for medication errors. Based on interview and record review, the facility failed to start a physician ordered medication for Resident (R)1, that resulted in 22 days without the ordered medication.

Inspectors wroteThe facility reported a census of 50 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for three of the three Certified Nurse Aides (CNA) reviewed, CNA M, CNA N and CNA O and failed to complete an annual performance review at least once every 12 months for two of the Certified Medication Aides (CMA) reviewed, CMA R and CMA S.

Inspectors wroteThe facility reported a census of 50 residents. Based on observation and interview, the facility failed to maintain a two-inch air gap between the ice machine drainpipe and drain in the kitchen to prevent back up of contaminated water into the ice machine.

Inspectors wroteThe facility reported a census of 50 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to weekend staffing, when the facility failed to accurately report weekend staffing during the third and fourth quarter of 2023. Findings Included: - Review of the 'Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY) Quarter 3, 2023 (April 1-June 30) and Quarter 4 (July-September), 2023 revealed extremely low weekend staffing. Review of the Staffing Sheets from April 2023 through September 2023, revealed equal staffing on the weekends as during the week. [...]

Inspectors wroteThe facility reported a census of 50 residents. Based on observation and interview, the facility failed to ensure to maintain the environment in a safe, sanitary, and homelike manner to promote the well-being of the residents.

Inspectors wroteThe facility reported a census of 50 residents with 17 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for four of the residents sampled, including Resident (R)28 and R43, regarding fall interventions, and R 9 and R 19 regarding specific, individualized parameters for hypertensive medications (medications used to lower blood pressure-BP).

Inspectors wroteThe facility reported a census of 50 residents with 17 residents selected for review, which included three residents reviewed for positioning/mobility. Based on observation, interview, and record review, the facility failed to ensure restorative services for one Resident (R)33, of the three residents reviewed for positioning/mobility.

Inspectors wroteThe facility reported a census of 50 residents with 17 residents included in the sample, including two residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to initiate appropriate interventions following non-injury falls for two Residents (R)28 and R 43.

Inspectors wroteThe facility reported a census of 50 residents with 17 residents selected for review, which included one resident reviewed for dialysis services. Based on observation, interview, and record review, the facility failed to ensure staff assessed one Resident (R) 13, post hemodialysis (a procedure where impurities or wastes were removed from the blood).

Inspectors wroteThe facility identified a census of 50 residents with 17 residents sampled, including one resident reviewed for insulin use. Based on interview, record review, and observation, the facility failed to follow physician's orders for one sampled Resident (R)11, regarding notification to the physician of blood sugars (BS) outside of parameters, as ordered.

Inspectors wroteThe facility reported a census of 50 residents with 17 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure two Resident (R) 9 and R 19 remained free from unnecessary medications related to failure to hold hypertensive medications (medications used to lower blood pressure).

Inspectors wroteThe facility reported a census of 53 residents, with one, Resident (R)1, reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure staff provided a safe environment as free of accidents as possible, when Certified Nurse Aide (CNA) M failed to apply the lap/shoulder belt on R1 prior to transport in the facility van to an appointment out of town. While traveling on the highway at approximately 67 miles per hour, CNA M looked in the rearview mirror, noted R1 to be dozing, and when CNA M looked back at the road, the vehicle in front of her had their brakes and left turn signal on. CNA M slammed on the brakes to avoid hitting the vehicle in front of the facility van, which caused R1 to fall out of the wheelchair and approximately three to four feet to the facility van floor. [...]

Inspectors wroteThe facility reported a census of 54 residents with 17 residents sampled, including one resident reviewed for pressure ulcers (PU). Based on record review, interview, and observations, the facility failed to ensure appropriate treatment and services for the one Resident (R)4, with the failure to prevent the development of one unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) PU.

Inspectors wroteThe facility reported a census of 54 residents. Based on interview and record review, the facility failed to provide sufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of the residents residing in the facility

Inspectors wroteThe facility reported a census of 54 residents. Based on observation and interview, the facility failed to store, prepare, and serve food in a sanitary manner, for the residents of the facility.

Inspectors wroteThe facility reported a census of 54 residents with 17 residents sampled. Based on interview, record review, and observation, the facility failed to provide proper infection control practices for three residents, including: (R)4 and R47, regarding unsanitary pressure ulcer/wound dressing changes and R 8, regarding urinary catheter tubing directly on the floor.

Inspectors wroteThe facility reported a census of 54 residents and identified 11 as unvaccinated. Based on interview and record review, the facility failed to ensure staff provided COVID-19 vaccination information/education which included benefit verses risk to ensure informed consent/declination for six of the 11 residents identified, including Resident (R)28, R7, R12, R35, R50 and R101 as required.

Inspectors wroteThe facility reported a census of 54 residents. The facility had one kitchen with one stove that two ovens for staff to cook meals for the residents of the facility. Based on observation and interview the facility failed to ensure the two ovens were in adequate safe working condition, for the residents of the facility.

Inspectors wroteThe facility reported a census of 54 residents with four reviewed for insulin administration. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure nursing, administration of insulin, and related to attain or maintain the highest physical, mental and psychosocial well-being of the residents residing the in the facility.

Inspectors wroteThe facility reported a census of 54 residents with 17 selected for review which included five residents selected for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure administration of medications as ordered for three of the five selected residents including: residents (R)29 when the staff failed to administer the potassium supplement (a medication to provide a balance of electrolytes when taking medication to remove excess fluid from the body) and two residents (R) 15 and R37, when staff failed to administer 08:00 PM doses of insulin (a medication to control blood sugar) within the timeframe, as ordered by the physician.

Inspectors wroteThe facility reported a census of 54 residents. Based on observation, interview and record review, the facility failed to provide palatable (pleasant to taste) meals for at least six interviewable residents (R) 15, 21, 153, 7, 32 and 47.

Inspectors wroteThe facility reported a census of 54 residents with 17 selected for review which included two residents reviewed for other skin conditions. Based on observation, interview and record review, the facility failed to provide sanitary dressing change for one of the two sample residents (R)47, to promote healing and prevent infection.

Inspectors wroteThe facility reported a census of 54 residents with 17 residents sampled, including five residents reviewed for accidents. Based on interview, record review and observation, the facility failed to initiate appropriate interventions to keep one Resident (R)153 from falls, and failed to ensure one bariatric shower chair was in safe condition for residents who used it, on one of two halls of the facility.

Inspectors wroteThe facility reported a census of 54 residents with 17 residents sampled, including two residents reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview and record review, the facility failed to appropriately handle the urinary catheter bag during cares for one of the two samples, Resident (R)8, in a manner to prevent urinary tract infections.

Inspectors wroteThe facility reported a census of 54 residents with 17 selected for review which included one resident reviewed for dialysis services. Based on observation, interview and record review, the facility failed to ensure follow-up on communications from the dialysis center for the one sampled resident(R)47.

Inspectors wroteThe facility reported a census of 54 residents with five selected for review for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure one of the five residents (R)29, medications were ordered and followed up on in a timely manner.

Inspectors wroteThe facility reported a census of 54 residents with 17 selected for review which included two residents reviewed for nutritional services. Based on observation, interview and record review, the facility failed to provide a physician ordered therapeutic renal diet for one of the two sampled residents, (R)47.