Diversicare of Council Grove

Inspectors wroteBased on interviews, observation, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high-contact care) while providing direct care to a Resident (R) 5 with open wounds to her left heel and left gluteal (buttock) fold. Additionally, the facility failed to ensure adequate hand hygiene during a wound measurement for R1. The facility failed to properly transport clean linen and personal linens in a sanitary manner to prevent cross contamination.

Inspectors wroteBased on interview and record review the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program (IPCP).

Inspectors wroteFive Certified Nurse Aide (CNA) staff who worked in the facility for more than 12 months were reviewed for the required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff with the required topics and no less than 12 hours per year.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete the Care Area Assessment (CAA- analysis of findings), related to a Comprehensive Minimum Data Set (MDS), for seven Residents (R)2, R3, R4, R7, R25, R48, and R52, to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate of less than five percent when two errors were identified, resulting in a medication error rate of 7.41 percent.

Inspectors wroteBased on interview and record review the facility failed to offer and provide or obtain an informed declination for the COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus) for Resident (R) 5, R44, R8, R48, and R49.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Long-Term Care Ombudsman in writing of Resident (R) 53's discharge from the facility. The facility failed to complete a discharge summary which included recapitulation of R6's stay and/or reconciliation of his medications following discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for activities of daily living (ADLs) for Resident (R) 8, who was not showered for two weeks, and R25 had dirty fingernails.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 25 when staff failed to respond to R25's requests for help and failed to provide foot pedals when staff propelled the wheelchair.

Inspectors wroteBased on interview and record review the facility failed to offer and provide or obtain an informed declination for the influenza vaccine (vaccine designed to prevent highly contagious viral infection) form to Resident (R) 5, and R8.

Inspectors wroteThe facility reported a census of 47 residents, with two residents reviewed for wounds. Based on observation, interview, and record review, the facility failed to provide adequate wound care for Resident (R)1 to prevent the wound from being contaminated with maggots (fly larvae). This deficient practice led to R1's right lower leg wound becoming contaminated with maggots, which caused physical and psychosocial discomfort.

Inspectors wroteThe facility reported a census of 46 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment in the common living area for the residents of the facility. This placed the affected residents at risk for decreased quality of life.

Inspectors wroteThe facility reported a census of 46 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to inadequate hand hygiene during wound care and inadequate cleaning of furniture. This deficient practice had the potential to spread possible infections to the residents in the facility.

Inspectors wroteThe facility had a census of 46 residents. Based on observation, interview, and record review, the facility failed to ensure effective pest control in the facility. This deficient practice placed the affected residents of the facility at risk for decreased health and wellness. (Refer to F684)

Inspectors wroteThe facility reported a census of 46 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to treat residents in a dignified manner when Resident (R)2 received personal care without privacy. This deficient practice placed the resident at risk for decreased psychosocial well-being and embarrassment.

Inspectors wroteThe facility identified a census of 52 residents. The sample included one resident reviewed for involuntary discharge. Based on observation, record review, and interview, the facility initiated a 30-day involuntary discharge for Resident (R)1 though R1's clinical record did not contain evidence to validate the reason for the involuntary discharge. This deficient practice placed R1 at risk for impaired health and well-being and involuntary discharge from the facility.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, 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 on the Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report weekend staffing for Quarter 3 of 2023 (April 1-June 3), Quarter 4 of 2023 (July 1-September 30), Quarter 1 of 2024 (October 1-December 31) and Quarter 2 of 2024 (January 1-March 31). Findings Included: [...]

Inspectors wroteThe facility reported a census of 43 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to review and revise the care plans for four or the sampled residents, Resident (R) 18 and R8 for scabies (a contagious skin infection caused by mites) infections, R41 for use of urine collection leg bag device, and R19 for self-removal of anchoring device, and alternative catheter stabilizing devices.

Inspectors wroteThe facility reported a census of 43 residents with 14 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to two Residents (R)19, by failing to cover the resident's bare lap, which left the silicone portion of an indwelling urinary catheter (a catheter that is inserted into the bladder and left in place for many days or weeks) visible to others while in the dining room and R41 for failure to utilize a dignity cover for the collection leg bag of the resident's indwelling urinary catheter while in the dining room and common's area.

Inspectors wroteThe facility reported a census 43 residents with 14 residents sampled, which included Resident (R)18 reviewed for reasonable accommodation. Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of R18's needs when the facility failed to follow up on recommendations for a different wheelchair, which would meet the resident's physical needs and preference to maintain his independence.

Inspectors wroteThe facility reported a census 43 residents with 14 residents sampled, which included one Resident (R)18 reviewed for notification of change in condition. Based on observation, interview, and record review, the facility failed to notify the resident's chosen representative when the resident required a new form of treatment, related to the resident's newly diagnosed scabies infestation.

Inspectors wroteThe facility reported a census of 43 residents with 14 residents selected for review, which included three residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure staff provided safe transfers for one, Resident (R)19, of the three residents reviewed.

Inspectors wroteThe facility reported a censes of 43 residents with 14 residents selected for review and three residents reviewed for bowel and bladder. Based on observation, interview, and record review, the facility failed to analyze one Resident (R) 95's three-day voiding diary to determine type of incontinence and pattern of incontinence to mitigate fall occurrences and provide sanitary urinary catheter (a tube that drains urine from the bladder) care for one resident (R19) to prevent urinary tract infections of the three residents reviewed.

Inspectors wroteThe facility reported a census of 43 residents, 14 residents selected for review, which included one resident reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure staff provided sanitary care to respiratory equipment and administration of aerosolized (vapor) medication for one Resident (R) 39.

Inspectors wroteThe facility reported a census of 43 residents with 14 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure two Residents (R) 12 and R 27 remained free from unnecessary medications related to failure to administer as needed (PRN) medications for bowel movements (BM).

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, record review, and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, on a daily basis, for the 43 residents who resided in the facility.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required committee members attended the Quality Assessment and Assurance (QAA) Committee meetings at least quarterly. This placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with no COVID (an acute respiratory illness capable of producing severe respiratory complications including death) positive residents identified. Based on observation, record review and interview the facility failed to identify high transmission rates for COVID and failed to ensure facility staff wore masks to protect residents and staff, and prevent COVID transmission for the 42 residents residing in the facility. This placed all residents at increased risk for transmission of infectious disease.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a safe, clean comfortable and homelike environment in one of three halls on the A unit and one of three halls and the commons area by the nurse's station in the B unit. This placed the residents at risk for an unsafe and uncomfortable environment.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with six reviewed for activities of daily living (ADL). Based on observation, interview and record review the facility failed to provide shaving for dependent Resident (R) 28, which placed the resident at risk of impaired comfort and dignity.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to prevent a decrease in range of motion (ROM)/mobility for one of six residents, Resident (R) 4, reviewed for activities of daily living. This placed R4 at risk of further contractures (abnormal permanent fixation of a joint) and impaired mobility. [...]

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure and record consistent medication administration for Resident (R) 29, and R28. This placed the residents at risk for ineffective medication regimen.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observations, record review, and interview the facility failed to provide an appropriate diagnosis for R29's antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication. This placed R29 at risk for complications related to receiving an unnecessary antipsychotic medication.