Diversicare Of Haysville

F-F554)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 On 03/12/25 at 12:16 AM, Certified Medication Aide (CMA) R stated the medication carts were to be locked when not in use or unsupervised. She stated nurses and medication aides have been educated not to leave Level of Harm - Minimal harm or the carts unlocked. She stated medication should never be left unsupervised in the resident's rooms. She potential for actual harm stated staff should complete narcotics counts at each shift change to verify all medications were present.

Residents Affected - Many On 03/12/25 at 12:35 PM, Licensed Nurse (LN) G stated staff were expected to lock the med carts when

they walked away from them. She stated nursing staff were expected to complete and sign off on narcotic medications at the beginning of each shift with two nurses signing. She stated staff should never leave medications in the resident's rooms unsupervised.

On 03/12/25 at 01:24 PM, Administrative Nurse D stated staff were expected to check the medication carts to ensure they were secured before leaving them. She stated the nurses were expected to count and verify narcotic cards each shift as a correction plan for the loss of medications. She stated medications were expected to be destroyed with two nurses witnessing and signing off.

The facility was unable to provide a policy related to competent staffing as requested on 03/13/25.

The facility failed to ensure staff possessed the appropriate skills and knowledge to safely handle, store, and administer resident medications. This deficient practice placed the residents at risk for potential medication errors and side effects.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45668 potential for actual harm

The facility identified a census of 81 residents. The sample included 21 residents, with one reviewed for Residents Affected - Few dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R) 12 to promote the resident's highest practicable level of well-being. This deficient practice placed Resident R12 at risk for decreased quality of life, isolation, and impaired dignity.

Findings Included:

- The Medical Diagnosis section within Resident R12's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (difficulty swallowing), cognitive-communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), insomnia (difficulty sleeping), and need for assistance with personal cares.

Resident R12's Annual Minimum Data Set (MDS) dated [DATE REDACTED] noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted she used a wheelchair for mobility. The MDS noted she required partial to moderate assistance with bed mobility, transfers, dressing, bathing, personal hygiene, and toileting. The MDS noted no recent falls.

Resident R12's Functional Abilities Care Area Assessment (CAA) completed 02/16/25 indicated she was alert with some confusion. The CAA noted she may or may not voice her needs for assistance and had poor safety awareness. The CAA instructed staff to assist her with her daily care.

Resident R12's Care Plan initiated 06/03/24 indicated she had a self-care deficit related to her impaired cognition and dementia. The plan noted she required the assistance of one staff for transfers, dressing, bathing, bed mobility, grooming, and toileting. The plan instructed staff to provide hair, nail, and oral care daily and as needed. The plan lacked indication or interventions related to her dementia-related behaviors or refusal of care.

Resident R12's EMR under Progress Notes completed on 03/10/25 documented Resident R12 transferred herself from her wheelchair to the nurse's station chair and began grabbing items off the nurse's desk. The note revealed staff were unable to redirect her and she remained at the station for four to five hours. The note indicated she eventually agreed to go to bed.

Resident R12's EMR under Progress Notes completed on 11/20/24 documented Resident R12 was confused and asked to call

a cab to go home. The note reported that Resident R12 informed staff she had no money and didn't want to stay. The note indicated staff offered pudding but Resident R12 refused to eat it.

Resident R12's EMR under Progress Notes completed on 09/29/24 documented Resident R12 was educated not to eat roommates' food or drinks. The note indicated she was educated to keep her hands to herself.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Resident R12's EMR under Progress Notes revealed a note completed on 09/20/24 documented indicated Resident R12 became agitated at staff and threw a water pitcher while staff attempted a check and change. The note Level of Harm - Minimal harm or indicated she then threw feces at staff. The note indicated staff were unable to redirect Resident R12. No other potential for actual harm interventions were noted.

Residents Affected - Few Resident R12's EMR under Documentation Survey Report from 01/01/2025 to 03/12/25 (70 days reviewed) revealed

she received bathing on 10 occasions: 01/02/25, 01/06/25, 01/20/25, 01/23/25, 01/30/25, 02/03/25, 02/17/25, 03/03/25, 03/06/25, and 03/10/25. The report noted she refused on nine occasions in the reviewed period. Resident R12's EMR revealed no rationale or interventions offered for the refused bathing occurrences.

On 03/10/25 at 07:40 AM, Resident R12 sat in the dining area. Resident R12's hair was greasy and uncombed. She reported

she was not sure when her last bathing occurrence was and if staff offered to comb her hair.

On 03/11/25 at 12:30 PM, Resident R12 sat in her wheelchair in the dining room. Her hair was uncombed.

On 03/12/25 at 11:30 AM, Certified Medication Aide (CNA) R stated that Resident R12 had a history of refusing care and bathing. She stated staff would often ask to provide bathing assistance and report to the nurse if she refused. She stated that Resident R12 would also refuse to allow staff to assist with grooming and activities. She stated staff would allow time for Resident R12 to calm down and reoffer the care.

On 03/12/25 at 11:45 AM, Licensed Nurse (LN) G stated that Resident R12 refused bathing and care frequently. She stated staff should offer alternative care if she did not want bathing or showers. She stated Resident R12 sometimes had confusion but rarely was aggressive or not redirectable. She stated offering Resident R12 a snack was often effective. She stated the care plan should identify her behaviors and provide interventions to help staff understand how to calm her down.

On 03/12/25 at 01:30 PM, Administrative Nurse D stated that Resident R12 was often redirectable and loved sugary snacks. She stated staff were expected to be patient and allow her time to process what was asked. She stated staff were expected to provide options and alternatives to Resident R14 if she refused her daily care. She stated staff were expected to chart refusals and note what interventions were attempted.

The facility's Dementia Care revised 01/2016 noted the facility was to ensure care was provided in a consistent and dignified manner. The policy noted staff were to re-approach residents after refusals and respond to any behaviors of distress to ensure all unmet needs were addressed.

The facility failed to provide dementia-related care services for Resident R12 to promote the resident's highest practicable level of well-being. This deficient practice placed Resident R12 at risk for decreased quality of life, isolation, and impaired dignity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41037

Residents Affected - Few The facility identified a census of 81 residents. The sample included 21 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations for Resident (R) 61's as needed psychotropic medication (alters mood or thought). The facility also failed to ensure the CP identified and reported irregularities regarding lack of dosing instructions for Voltaren (topical pain reliever medication) gel and the lack of monitoring antihypertensive (a class of medication used to treat high blood pressure) medications for Resident R54. The facility also failed to ensure the CP identified and reported irregularities regarding lack of documentation of Resident R14's oxygen saturation monitoring. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications.

Findings included:

- Resident R61's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and congestive heart failure (CHF -

a condition with low heart output and the body becomes congested with fluid).

The Annual Minimum Data Set (MDS) dated [DATE REDACTED] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented Resident R61 had received insulin (medication to regulate blood sugar), antidepressant (a class of medications used to treat mood disorders), diuretic (a medication to promote the formation and excretion of urine) medication, and opioid (a class of controlled drugs used to treat pain) medication during the observation period. The MDS lacked documentation a gradual dose reduction (GDR) was attempted. The MDS also lacked documentation there was physician documentation a GDR was contraindicated. The MDS lacked documentation a drug regimen review was completed during the observation period.

The Quarterly MDS dated [DATE REDACTED] documented a BIMS score of 13 which indicated intact cognition. The MDS documented that Resident R61 had received insulin, antidepressant medication, diuretic medication, and opioid medication during the observation period. The MDS lacked documentation a GDR was attempted. The MDS also lacked documentation there was physician documentation a GDR was contraindicated. The MDS lacked documentation a drug regimen review was completed during the observation period.

Resident R61's Psychotropic Drug Use Care Area Assessment (CAA) dated 06/19/24 documented the physician, pharmacist, and nursing staff would monitor her for adverse side effects of her psychotropic medications.

Resident R61's Care Plan dated 05/08/24 documented the nursing staff would administer her medication as ordered.

The plan of care documented the nursing staff would monitor for side effects and effectiveness.

Resident R61's EMR under the Orders tab revealed the following physician orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Trazodone (antidepressant) hcl oral tablet 50 milligrams (mg) give half tablet (25mg) by mouth as needed for behaviors; anxiety doctor does not care how close two doses are as long as only two doses a day dated Level of Harm - Minimal harm or 03/07/25. potential for actual harm

Review of Resident R61's Monthly Medication Review (MMR) from February 2024 through February 2025 provided by Residents Affected - Few the facility, lacked evidence the attending physician had reviewed or addressed the CP's recommendation from 10/17/24. The facility was unable to provide evidence the physician reviewed the recommendations made on 10/17/24 upon request.

Review of Resident R61's EMR under the Progress Notes tab a Pharmacy Review note dated 10/17/24 at 05:11 PM documented recommendations were made, review of the Clinical Pharmacy Report Review Resident R61's EMR under the Documents tab revealed an unaddressed and unsigned Monthly Medication Review (MMR) dated 10/17/24.

On 03/11/25 at 07:20 AM, Resident R61 propelled herself in the wheelchair to the dining room.

On 03/12/25 at 12:42 PM, Licensed Nurse (LN) G stated she would review the MMRs at times after the physician had reviewed and signed the recommendations. LN G stated she made any changes in the resident's EMR.

On 03/12/25 at 01:29 PM, Administrative Nurse D stated she would expect the as-needed psychotropic medications to have a 14-day stop date or duration for the administration ordered. Administrative Nurse D stated that Resident R61's attending physician was notified of the CP's irregularities and failed to respond or address

the recommendations.

The facility's Medication Regimen Review (MRR) policy dated 11/28/16 documented the center would meet MRR requirements including the timely notification of consultant pharmacist identified irregularities that require urgent action to protect patients/residents. The center would encourage the Physician/Prescriber or other Responsible Parties receiving the MRR to act upon the recommendations contained in the MRR. The attending physician would document the identified irregularity has been reviewed and what, if any, action has been taken to address the recommendations. If the attending physician has decided to make no change in

the medication, the attending physician should document the rationale in the residents' health records. The center would alert the Medical Director when MRRs are not addressed by the attending physician/prescriber

in a timely manner.

The facility failed to ensure the physician reviewed and addressed the CP recommendations for Resident R61. This deficient practice placed Resident R61 at risk for unnecessary medication use, side effects, and physical complications.

41713

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 - Resident R14's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition Level of Harm - Minimal harm or characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition potential for actual harm where the heart is unable to pump enough blood to meet the body's needs), diabetes mellitus (DM - when

the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), bipolar Residents Affected - Few disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and fracture of left tibia (broken bone of the lower leg).

Resident R14's Significant Change Minimum Data Set (MDS) dated [DATE REDACTED], documented he had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. Resident R14 required substantial assistance to dependent on staff for functional abilities and activities of daily living (ADL). Resident R14 required the use of a wheelchair for mobility. Resident R14 took an anticoagulant (a class of medications used to prevent the blood from clotting), an antidepressant (a class of medications used to treat mood disorders), an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), and insulin (a hormone that lowers the level of glucose in the blood) regularly. Resident R14 required oxygen therapy.

Resident R14's Functional Abilities Care Area Assessment (CAA) dated 11/04/24, documented that he was alert, had some confusion and was able to voice his needs for assistance. Resident R14 needed assistance for ADLs, and could be self-limiting, and may refuse care. Resident R14 was participating in therapy but had a history of refusing. Resident R14 will remain at the long-term care center.

Resident R14's Care Plan, revised on 02/12/25, directed staff to monitor him for acute signs and symptoms of respiratory insufficiency and to notify the physician. Resident R14's care plan lacked staff direction about maintaining his O2 saturation levels above 90%.

Resident R14's Orders tab of the EMR documented a physician's order dated 10/23/24 to maintain O2 saturation (percentage of oxygen in the blood) above 90 percent (%) every shift for COPD respiratory failure. This order was discontinued on 02/21/25.

Resident R14's Orders tab of the EMR documented a physician's order dated 02/22/25 to maintain O2 saturation (percentage of oxygen in the blood) above 90 percent (%), Resident R14 was currently on room air.

A review of Resident R14's Orders tab of the EMR lacked any order to administer supplemental O2 if his O2 saturation was below 90%.

A review of the CP's Note to Attending Physician/Prescriber recommendations from October 2024 to February 2025 revealed no recommendation to monitor and document his O2 saturation.

A review of Resident R14's Medication Administration Record (MAR) and Treatment Order Record (TAR) from October 2024 to 02/21/25 revealed the O2 saturation had been obtained and documented three times daily as ordered.

A review of Resident R14's MAR and TAR from 02/22/25 to the present revealed that staff had signed off on the order to maintain O2 saturation above 90%, but the TAR lacked monitoring and documenting of the O2 saturation reading on 14 of 14 opportunities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 A review of Resident R14's MAR and TAR for March 2025 revealed that staff had not obtained and documented Resident R14's O2 saturation on 20 of 20 opportunities. Level of Harm - Minimal harm or potential for actual harm On 03/11/25 at 09:18 AM, Resident R14 laid on his back on his bed. Resident R14's head of the bed was elevated, and the call light was within reach. Residents Affected - Few

On 03/12/25 at 01:30 PM, Administrative Nurse D stated she would expect the CP to identify and report if Resident R14's O2 saturation level was not being monitored and documented on the TAR. Administrative Nurse D stated that Resident R14's order had been changed recently to be done only twice daily. Administrative Nurse D stated the order had not been input correctly to include documenting the O2 reading.

The CP could not be reached for an interview.

The facility's Medication Regimen Review (MRR) policy dated 11/28/16 documented the center would meet MRR requirements including the timely notification of consultant pharmacist identified irregularities that require urgent action to protect patients/residents. The center would encourage the Physician/Prescriber or other Responsible Parties receiving the MRR to act upon the recommendations contained in the MRR. The attending physician would document that the identified irregularities were reviewed and what, if any, action has been taken to address the recommendations. If the attending physician has decided to make no change

in the medication, the attending physician should document the rationale in the residents' health records. The center would alert the Medical Director when MRRs are not addressed by the attending physician/prescriber

in a timely manner.

The facility failed to ensure the CP identified and reported Resident R14's O2 not being monitored and documented as

the physician ordered. This placed Resident R14 at risk for unnecessary medication administration and related complications.

- Resident R54's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk).

Resident R54's Admission Minimum Data Set (MDS) dated [DATE REDACTED], documented she had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. Resident R54 required moderate assistance from staff for oral hygiene, upper body dressing, and personal hygiene. Resident R54 was dependent on staff assistance with all other functional abilities and activities of daily living (ADL). Resident R54 used a wheelchair to assist with mobility. Resident R54 received an anticoagulant (a class of medications used to prevent the blood from clotting), a diuretic (a medication to promote the formation and excretion of urine), and other medications regularly.

Resident R54's Functional Abilities Care Area Assessment (CAA) dated 10/08/24, documented she was alert, orientated, and able to voice her needs. Resident R54 required assistance from staff for all daily care. Resident R54 minimally participated in therapy.

Resident R54's Care Plan revised on 03/10/25, directed staff to administer medications as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Resident R54's Orders Tab of the EMR documented a physician's order dated 10/03/24 for digoxin (a medication used to treat heart rhythm disorders) 125 milligrams (mg) to give one tablet by mouth one time a day for atrial Level of Harm - Minimal harm or fibrillation (A-Fib - a rapid, irregular heartbeat). This order was discontinued on 02/12/25. This order lacked a potential for actual harm parameter for the pulse.

Residents Affected - Few Resident R54's Orders Tab of the EMR documented a physician's order dated 02/25/25 for metoprolol succinate (a beta blocker medication) 100 mg by mouth daily for HTN. The order lacked a parameter for the blood pressure and pulse.

Resident R54's Orders tab of the EMR documented a physician's order dated 02/25/25 for digoxin 125 mg by mouth daily for A-Fib. This order lacked a parameter for the pulse prior to administration.

Resident R54's Orders tab of the EMR documented a physician's order for diclofenac (a topical medication used to treat mild to moderate pain and arthritis) one percent (1%) gel to be applied to the knees and shoulders topically three times daily. This order lacked a dosage amount to be applied to the affected areas.

A review of Resident R54's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for October 2024 to March 2025 revealed that a pulse reading was not obtained and documented before the administration of her physician-ordered digoxin. Resident R54's blood pressure and pulse were not monitored and documented prior to the administration of her physician-ordered metoprolol.

A review of the CP's Note to Attending Physician/Prescriber recommendations from October 2024 to February 2025 revealed the CP failed to identify and recommend monitoring and documenting Resident R54's pulse

before the administration of digoxin, the blood pressure, and pulse before the administration of metoprolol, and failed to identify Resident R54's diclofenac lacked a dosage amount.

On 03/11/25 at 12:05 PM, Resident R54 was propelled by staff from her room to the dining room for lunch.

On 03/12/25 at 12:16 PM, Certified Medication Aide (CMA) R stated a pulse should be obtained and documented before digoxin was given to make sure the pulse was not too low. CMA R stated she thought that blood pressure and pulse should be taken before giving a beta blocker like metoprolol.

On 03/12/25 at 12:41 PM, Licensed Nurse (LN) G stated that when a medication was entered into the EMR it should ask the person entering the order if it was a blood pressure medication there should be a pulse and or

a blood pressure reading obtained before administration. LN G stated any order should indicate a dosage amount to give or apply.

On 03/12/25 at 01:30 PM, Administrative Nurse D stated all medications should have a dosage amount. Administrative Nurse D stated the physician or the nurse practitioner input their own orders into the EMR, but

the nurses would enter orders if a phone order was received when a resident returned from an appointment, or from the hospital. Administrative Nurse D expected staff to ensure that a pulse was obtained prior to administration of digoxin as well as a blood pressure for metoprolol.

The CP could not be reached for an interview.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 The facility's Medication Regimen Review (MRR) policy dated 11/28/16 documented the center would meet MRR requirements including the timely notification of consultant pharmacist identified irregularities that Level of Harm - Minimal harm or require urgent action to protect patients/residents. The center would encourage the Physician/Prescriber or potential for actual harm other Responsible Parties receiving the MRR to act upon the recommendations contained in the MRR. The attending physician would document that the identified irregularity has been reviewed and what if any, action Residents Affected - Few has been taken to address the recommendations. If the attending physician has decided to make no change

in the medication, the attending physician should document the rationale in the residents' health records. The center would alert the Medical Director when MRRs are not addressed by the attending physician/prescriber

in a timely manner.

The facility failed to ensure that the CP identified and reported when Resident R54's physician-ordered diclofenac gel lacked a dosage amount. The facility further failed to ensure the CP identified and reported that Resident R54's pulse had not been obtained prior to the administration of digoxin and failed to ensure Resident R54's blood pressure had been obtained prior to the administration of metoprolol. These deficient practices placed Resident R54 at risk of unnecessary medication administration and related complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41713 potential for actual harm

The facility identified a census of 81 residents. The sample included 21 residents, with five sampled Residents Affected - Few residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 14's oxygen (O2) saturation was monitored and documented as physician ordered. The facility failed to ensure staff monitored and documented Resident R54's pulse for her antiarrhythmic (medications used to treat abnormal heart rhythms) and Resident R54's blood pressure for her beta blocker (a medication used to treat high blood pressure and other cardiac conditions). This deficient practice placed these residents at risk for unnecessary medication administration and related complications.

Findings included:

- Resident R14's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition where the heart is unable to pump enough blood to meet the body's needs), diabetes mellitus (DM - when

the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and fracture of left tibia (broken bone of the lower leg).

Resident R14's Significant Change Minimum Data Set (MDS) dated [DATE REDACTED], documented he had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. Resident R14 required substantial assistance to dependent on staff for functional abilities and activities of daily living (ADL). Resident R14 required the use of a wheelchair for mobility. Resident R14 took an anticoagulant (a class of medications sued to prevent the blood from clotting), an antidepressant (a class of medications used to treat mood disorders), an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), and insulin (a hormone that lowers the level of glucose in the blood) regularly. Resident R14 required oxygen therapy.

Resident R14's Functional Abilities Care Area Assessment (CAA) dated 11/04/24, documented that he was alert, had some confusion, and was able to voice his needs for assistance. Resident R14 needed assistance for ADLs, and can be self-limiting, and may refuse cares. Resident R14 was participating in therapy but had a history of refusing. Resident R14 will remain at the long-term care center.

Resident R14's Care Plan, revised on 02/12/25, directed staff to monitor him for acute signs and symptoms of respiratory insufficiency, and to notify the physician. Resident R14's care plan lacked staff direction about maintaining his O2 saturation levels above 90%.

Resident R14's Orders tab of the EMR documented a physician's order dated 02/21/25 for O2 to maintain O2 saturation (percentage of oxygen in the blood) above 90 percent (%).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 A review of Resident R14's Medication Administration Record (MAR) and Treatment Order Record (TAR) for February 2025 revealed that staff had signed off on the order to maintain O2 saturation above 90%. The TAR lacked Level of Harm - Minimal harm or monitoring and documenting of the O2 saturation reading on 14 of 14 opportunities. potential for actual harm

A review of Resident R14's MAR and TAR for March 2025 revealed that staff had not obtained and documented Resident R14's Residents Affected - Few O2 saturation on 20 of 20 opportunities.

On 03/11/25 at 09:18 AM, Resident R14 laid on his back on his bed. Resident R14's head of the bed was elevated, and the call light was withing reach.

On 03/12/25 at 12:16 PM, Certified Medication Aide (CMA) R, stated that if a resident had an order for O2 saturation, the MAR or TAR should have a place where the O2 reading can be documented.

On 03/12/25 at 12:41 PM, Licensed Nurse (LN) G stated Resident R14's MAR or TAR should have a slot on the O2 order where the O2 saturation reading could be documented. LN G stated when the order was input into the EMR it must not been marked to include the slot to enter the O2 saturation reading. LN G stated Resident R14's O2 saturation should be monitored and documented.

On 03/12/25 at 01:30 PM, Administrative Nurse D stated if a resident was receiving O2 the saturation level should be monitored and documented on the TAR. Administrative Nurse D stated when the order was input into the EMR the staff member did not mark the area for the reading. Administrative Nurse D stated that Resident R14's MAR/TAR would be updated to ensure the O2 reading was obtained.

The Verbal Orders policy dated February 2025 documented physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who was legally authorized to do so. Enter the order into the medical record electronically as per the software system guidelines.

The facility failed to ensure the nursing staff monitored and documented Resident R14's O2 saturation as physician ordered. This placed Resident R14 at risk for unnecessary medication administration and related complications.

- Resident R54's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk.

Resident R54's Admission Minimum Data Set (MDS) dated [DATE REDACTED], documented she had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. Resident R54 required moderate assistance from staff for oral hygiene, upper body dressing, and personal hygiene. Resident R54 was dependent on staff assistance with all other functional abilities and activities of daily living (ADL). Resident R54 used a wheelchair to assist with mobility. Resident R54 received an anticoagulant (a class of medications sued to prevent the blood from clotting), a diuretic (a medication to promote the formation and excretion of urine), and other medications regularly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Resident R54's Functional Abilities Care Area Assessment (CAA) dated 10/08/24, documented she was alert, and orientated, and able to voice her needs. Resident R54 required assistance from staff for all daily cares. Resident R54 minimally Level of Harm - Minimal harm or participated in therapy. potential for actual harm Resident R54's Care Plan revised on 03/10/25, directed staff to administer medications as ordered. Residents Affected - Few Resident R54' Orders Tab of the EMR documented a physician's order dated 10/03/24 for digoxin (a medication used to treat heart rhythm disorders) 125 milligrams (mg) to give one tablet by mouth one time a day for atrial fibrillation (A-Fib - a rapid, irregular heartbeat). This order was discontinued on 02/12/25. This order lacked a parameter for the pulse.

Resident R54' Orders Tab of the EMR documented a physician's order dated 02/25/25 for metoprolol succinate (a beta blocker medication) 100 mg by mouth daily for HTN. The order lacked a parameter for the blood pressure and pulse.

Resident R54's Orders tab of the EMR documented a physician's order dated 02/25/25 for digoxin 125 mg by mouth daily for A-Fib. This order lacked a parameter for the pulse prior to administration.

Resident R54's Orders tab of the EMR documented a physician's order for diclofenac (a topical medication used to treat mild to moderate pain and arthritis) one percent (1%) gel to be applied to the knees and shoulders topically three times daily. This order lacked a dosage amount to be applied to the affected areas.

A review of Resident R54's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for October 2024 to March 2025 revealed that a pulse reading was not obtained and documented before the administration of her physician-ordered digoxin. Resident R54's blood pressure and pulse was not monitored and documented prior to administration of her physician-ordered metoprolol.

On 03/11/25 at 12:05 PM, Resident R54 was propelled by staff from her room to the dining room for lunch.

On 03/12/25 at 12:16 PM, Certified Medication Aide (CMA) R stated a pulse should be obtained and documented before digoxin was given to make sure the pulse was not too low. CMA R stated she thought that a blood pressure and pulse should be taken before given a beta blocker like metoprolol.

On 03/12/25 at 12:41 PM, Licensed Nurse (LN) G stated that when a medication was entered into the EMR it should ask the person entering the order if it was a blood pressure medication there should be a pulse and or

a blood pressure reading obtained before administration. LN G stated any order should indicate a dosage amount to give or apply.

On 03/12/25 at 01:30 PM, Administrative Nurse D stated all medications should have a dosage amount. Administrative Nurse D stated the physician, or the nurse practitioner input their own orders into the EMR, but the nurses would enter orders if a phone order was received, when a resident returned from an appointment, or from the hospital. Administrative Nurse D expected staff to ensure that a pulse was obtained prior to administration of digoxin as well as a blood pressure for metoprolol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 The Verbal Orders policy dated February 2025 documented physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who was legally authorized to do so. Level of Harm - Minimal harm or Enter the order into the medical record electronically as per the software system guidelines. potential for actual harm

The facility did not provide a policy regarding unnecessary medications as requested. Residents Affected - Few

The facility failed to ensure that Resident R54's physician-ordered diclofenac gel had a dosage amount. The facility further failed to ensure that Resident R54's pulse was obtained prior to administration of digoxin and failed to ensure Resident R54's blood pressure was obtained prior to administration of metoprolol. These deficient practices placed Resident R54 at risk of unnecessary medication administration and related complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 41037 Residents Affected - Some

The facility identified a census of 81 residents. The sample included 21 residents, five medication carts and three medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in three of the five medication carts. The facility also failed to label medication in one of the five medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens.

Findings included:

- During initial tour on 03/10/25 at 07:10 AM a medication cart on the 300 hallway was unlocked and unattended in the hallway. The unattended medication cart contained five opened, undated insulin (hormone that lowers the level of glucose in the blood) pens.

On 03/10/25 at 07:59 AM on hall 300 a medication cart with scheduled medication, scheduled narcotics, nasal sprays, was left unlocked with the medication keys and narcotic keys left in the cart.

On 03/10/25 at 09:20 AM a medication cart in the resident's quiet room was unlocked and unattended. The medication cart contained eye drops, skin creams, enemas and pain relieve cream.

On 03/12/25 at 12:17 PM, Certified Medication Aide (CMA) R stated the medication cart should never be left unlocked and unattended. CMA R stated the keys should never be left in the lock on the medication cart and left unattended.

On 03/12/25 at 12:42 PM, Licensed Nurse (LN) G stated the medication carts should not be left unlocked and unattended. LN G stated the keys should never be left in the lock of the medication unattended. LN G stated an insulin pen should be labeled at the time of the first administration.

On 03/12/25 at 01:29 PM, Administrative Nurse D stated she expected all medication carts to be locked when unattended. Administrative Nurse D stated the keys should never be left in the lock of the medication cart and then left unattended. Administrative Nurse D stated she expected insulin pens to be label and dated.

The facility was unable to provide a policy related medication storage.

The facility failed to properly to store and label medications. This deficient practice could potentially cause adverse consequences or ineffective treatment to the affected residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 45668

Residents Affected - Many The facility reported a census of 81 residents. The sample included 21 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing.

Findings included:

- A review of the facility's submitted PBJ data from 10/01/24 through 12/31/24 indicated the facility triggered for excessively low weekend staffing for Fiscal Year (FY) Quarter One 2025.

On 03/12/25 at 10:00 AM, the facility's Resident Council reported staffing on the weekends consistently changed due to call-offs. The council indicated the weekend manager would come in to fill shifts and help fill

in the gaps.

A review of the facility's working schedule, time sheets/punches, and posted staffing hours indicated no gaps or loss of hours. An inspection of the working schedule revealed weekend call-offs documented with administrative nurse coverage.

On 03/12/25 at 11:34 AM, Certified Medication Aide (CMA) R stated the facility had call-offs at times but would often have weekend managers to come in and either find replacements or work.

On 03/12/25 at 01:30 PM, Administrative Nurse D stated the facility did have a lot of call-offs recently due to

the influenza (contagious viral infection) outbreak. She stated the nurse managers came in to work and their time was not added to the PBJ submission.

The facility was unable to provide a policy related to staffing or PBJ reporting as requested on 03/12/25.

The facility failed to ensure accurate staffing hour information was submitted to the federal regulatory agency through PBJ when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 49634 potential for actual harm

The facility identified a census of 81 residents. The facility identified seven residents on Enhanced Barrier Residents Affected - Some Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care) and one person on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on record reviews, observations, and interviews, the facility failed to ensure to Resident (R) 130's Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) tubing was off the floor.

The facility additionally failed to store Resident R38 respiratory equipment in a sanitary manner. The facility further failed to sanitize a shared Hoyer (total body mechanical lift) between residents and failed to ensure the clean linen was covered in a sanitary manner when going through residents' halls. These deficient practices placed

the residents at risk for infectious diseases.

Included Findings:

- On 03/10/25 at 07:04 AM a walkthrough of the facility was completed.

An inspection of Resident R38's room revealed a nasal oxygen tubing wrapped around the back wheelchair handle, Resident R38's nasal tubing was not stored in a sanitary manner.

On 03/10/25 at 09:32 AM after transferring Resident R38 with Hoyer lift Certified Nurse's Aide (CNA) M pushed the Hoyer to the residents quit room and walked away, CNA M did not sanitize the Hoyer lift after Resident R38's transfer.

On 03/11/25 at 09:28 AM a laundry personal pushed clean linen down hall 100, and then down 200 halls, the laundry cart had clean towels, the laundry cart was not covered in a sanitary manner.

On 03/11/25 at 11:38 AM Resident R130's Foley catheter tubing laid directly on the floor. Resident R130's urinary bag was coved with a privacy bag and laid directly on the floor.

On 03/12/24 at 12:17 PM, Certified Medication Aide (CMA) R stated all oxygen tubing and equipment should be stored in a clean plastic bag to prevent contamination and respiratory infections. She stated Hoyer should be wiped down, and wipes were stored in the medication room. CMA R stated clean linen should be covered when going down hallways. She stated the Foley catheter and tubing should be off the floor.

On 03/12/25 at 12:41 PM, Licensed Nurse (LN) G stated all shared equipment should be sanitized between residents. She stated residents have bags to place all respiratory equipment in when not in use. LNG stated linen should always be covered, and the Foley catheter bag and tubing should be off the floor.

On 03/12/25 at 01:30 PM, Administrative Nurse D stated linens should be covered when going through hallways, and the Hoyer should be sanitized between resident use. Foley catheters bags and tubing should never be on the floor, and all residents have bags in their rooms or hanging from there canisters to place oxygen tubing when not in use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The facility's Infection Control policy dated 11/01/17 documented The facility's infection control polices and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help Level of Harm - Minimal harm or prevent and manage transmission of diseases and infections. potential for actual harm

The facility failed to ensure to Resident R130's Foley catheter and tubing was off the floor. The facility additionally Residents Affected - Some failed to store Resident R38 respiratory equipment in a sanitary manner. The facility further failed to sanitize a shared Hoyer between residents and failed to ensure the clean linen was covered in a sanitary manner when going through residents' halls. These deficient practices placed the residents at risk for infectious diseases.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 175133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175133 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Haysville 215 N Lamar Avenue Haysville, KS 67060

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 41037 potential for actual harm

The facility identified a census of 81 residents. The sample included 21 residents, with five reviewed for Residents Affected - Few immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 32. The facility also failed to administer PCV20 for Resident R54 who had given consent. This placed

these residents at increased risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease.

Findings included:

- Review of Resident R32's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication.

Review of Resident R54's clinical record revealed the PCV13 was administered on 11/15/20. The facility provided a signed consent for PCV20 dated 10/02/24. Resident R54's clinical record lacked documentation PCV20 was administered.

On 03/12/25 at 12:42 PM, Licensed Nurse (LN) G stated she would ask the resident at the time of admission about their immunizations. LN G stated she was not responsible with tracking immunizations.

On 03/12/25 at 01:29 PM, Administrative Nurse D stated the residents were asked at the time of admission about what immunizations they had received historically. Administrative Nurse D stated the Infection Preventionist was responsible to track and administer the immunizations. Administrative Nurse D stated Resident R54's PCV20 had been overlooked and was ordered from the pharmacy.

The facility's Pneumonia Vaccination Policy dated 11/28/16 documented the pneumococcal vaccination was offered to all patients and residents that meet eligibility criteria in accordance with current best practice clinical guidelines such as those from the Centers for Disease Control and Prevention (CDC).

The facility failed to offer and administer PCV20 or obtain informed declinations for Resident R32, who were eligible to receive the vaccination. The facility also failed to administer PCV20 after a consent was given for Resident R54 on 10/02/24. This placed Resident R32 and Resident R54 at increased risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 175133

F-F761)

On 03/11/25 at 09:48 AM, Resident R22's medications were again left on her bedside table unattended as she slept in her bed. (Refer to