A list of the most recent deficiencies for Diversicare of Council Grove. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-10 | 2023-01-27 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-05 | 2023-01-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-05 | 2023-01-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-05 | 2023-01-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-05 | 2023-01-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-12-05 | 2023-01-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-12-05 | 2023-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2023-01-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-07-27 | 2022-08-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Develop a communication plan. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-21 | 2021-05-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-02 | 2021-03-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-03-02 | 2021-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-02 | 2021-03-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-30 | 2019-06-21 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-05-30 | 2019-06-21 | N |
| Provide activities to meet all resident's needs. | Health | 2019-05-30 | 2019-06-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-30 | 2019-06-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-30 | 2019-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-30 | 2019-06-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-30 | 2019-06-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-05-30 | 2019-06-21 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-03-15 | 2019-03-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-03-15 | 2019-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-15 | 2019-03-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-03-15 | 2019-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-15 | 2019-03-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-15 | 2019-03-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-15 | 2019-03-22 | N |
