A list of the most recent deficiencies for Via Christi Village - Hays Inc. 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-10 | 2024-01-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-10 | 2024-01-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-10 | 2024-01-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-10 | 2024-01-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-10 | 2024-01-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-10 | 2024-01-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-10 | 2024-01-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-30 | 2024-01-05 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-11-30 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-30 | 2024-01-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-30 | 2024-01-05 | 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 | 2023-11-30 | 2024-01-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-11-30 | 2024-01-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-30 | 2024-01-05 | 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 | 2023-11-30 | 2024-01-05 | N |
| 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 locked, compartments for controlled drugs. | Health | 2023-11-30 | 2024-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-01-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-30 | 2024-01-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-30 | 2024-01-05 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-11-30 | 2024-01-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-30 | 2024-01-05 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-08-17 | 2023-07-28 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-03-28 | 2023-04-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-07 | 2023-01-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-13 | 2022-09-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-13 | 2022-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-13 | 2022-08-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-07 | 2022-08-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-07 | 2022-08-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-06-07 | 2022-08-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-07 | 2022-08-22 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-07 | 2022-08-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-07 | 2022-08-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-07 | 2022-08-22 | N |
| 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 locked, compartments for controlled drugs. | Health | 2022-06-07 | 2022-08-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-07 | 2022-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-07 | 2022-08-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-13 | 2022-08-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-13 | 2022-08-04 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-07-13 | 2022-08-04 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-19 | 2022-07-29 | 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 | 2022-07-19 | 2022-07-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-19 | 2022-07-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-02 | 2021-10-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-11-12 | 2020-11-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-11-12 | 2020-11-24 | N |
| 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 locked, compartments for controlled drugs. | Health | 2020-11-12 | 2020-11-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-04 | 2020-03-12 | N |
