D
47/100KEARNY COUNTY HOSPITAL LTCU Inspection Report, Violations & Safety Grade (LAKIN, Kansas)
607 COURT PL, LAKIN, Kansas 67860
Phone: 6203557836
CMS Overall:1/5
Overview & Bed Count
Certified Beds
40
Avg Residents/Day
17.6
Ownership
Government - County
Provider Type
Medicaid
County
Kearny
Sprinkler Systems
Yes
Special Focus
SFF Candidate
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing4/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Kansas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.33 | 0.73 | +0.60 |
| Total Nurse Hours per Resident per Day | 6.68 | 4.13 | +2.55 |
| CMS Staffing Rating | 4/5 | 3.5/5 | - |
| Nursing Staff Turnover | N/A | 48% | - |
Health Citation History
43 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-10-24 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2024-10-24 | Resident Assessment and Care Planning Deficiencies | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | F – Moderate Harm Potential |
| 2024-10-24 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | F – Moderate Harm Potential |
| 2024-10-24 | Nursing and Physician Services Deficiencies | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | F – Moderate Harm Potential |
| 2024-10-24 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-10-24 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | F – Moderate Harm Potential |
| 2024-10-24 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F – Moderate Harm Potential |
| 2024-10-24 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2024-10-24 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2024-10-24 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2024-10-24 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | F – Moderate Harm Potential |
| 2024-10-24 | Infection Control Deficiencies | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F – Moderate Harm Potential |
| 2024-10-24 | Nursing and Physician Services Deficiencies | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | F – Moderate Harm Potential |
| 2024-10-24 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | E – Moderate Harm Potential |
| 2024-10-24 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-10-24 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | E – Moderate Harm Potential |
| 2024-10-24 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-10-24 | Resident Assessment and Care Planning Deficiencies | Assure that each resident’s assessment is updated at least once every 3 months. | E – Moderate Harm Potential |
| 2024-10-24 | Resident Assessment and Care Planning Deficiencies | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | E – Moderate Harm Potential |
| 2024-10-24 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2024-10-24 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2024-10-24 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-10-24 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E – Moderate Harm Potential |
| 2024-10-24 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2024-10-24 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2024-10-24 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-10-24 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-10-24 | Nursing and Physician Services Deficiencies | Ensure that the resident and his/her doctor meet face-to-face at all required visits. | D – Moderate Harm Potential |
| 2024-10-24 | Quality of Life and Care Deficiencies | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D – Moderate Harm Potential |
| 2024-10-24 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2024-10-24 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-10-24 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D – Moderate Harm Potential |
| 2024-10-24 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | C – Minimal Harm Potential |
| 2022-12-07 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2022-12-07 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F – Moderate Harm Potential |
| 2022-12-07 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2022-12-07 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2022-12-07 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2022-12-07 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2022-12-07 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2021-05-27 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K – Immediate Jeopardy |
| 2021-05-27 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2021-05-27 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
Fire Safety Citation History
21 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-10-24 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2024-10-24 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | F – Moderate Harm Potential |
| 2024-10-24 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | F – Moderate Harm Potential |
| 2024-10-24 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-10-24 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-10-24 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-10-24 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2024-10-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-10-24 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2024-10-24 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2024-10-24 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | D – Moderate Harm Potential |
| 2024-10-24 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2024-10-24 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | D – Moderate Harm Potential |
| 2024-10-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2022-12-07 | Construction Deficiencies | Install a two-hour-resistant firewall separation. | F – Moderate Harm Potential |
| 2022-12-07 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2022-12-07 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2021-05-27 | Construction Deficiencies | Install a two-hour-resistant firewall separation. | F – Moderate Harm Potential |
| 2021-05-27 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2021-05-27 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2021-05-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
Total Penalties & Fines
$60,125
Total Fine Amount (CMS)
7
Number of Fines
7
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-02-20 | Fine | $4,893 | - |
| 2024-02-12 | Fine | $4,893 | - |
| 2024-01-22 | Fine | $14,679 | - |
| 2024-01-08 | Fine | $4,893 | - |
| 2024-01-02 | Fine | $4,545 | - |
| 2023-12-11 | Fine | $13,635 | - |
| 2023-11-06 | Fine | $12,587 | - |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the LAKIN area at no cost.
Find Safe, Vetted Facilities Near LAKIN
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.