Diversicare of Council Grove

In the surveyor’s words

From the most serious findings on record at Diversicare of Council Grove, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 8, 2025

  The facility reported a census of 47 residents, with two residents reviewed for wounds. Based on observation, interview, and record review, the facility failed to provide adequate wound care for Resident (R)1 to prevent the wound from being contaminated with maggots (fly larvae). This deficient practice led to R1's right lower leg wound becoming contaminated with maggots, which caused physical and psychosocial discomfort.Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic veinous hypertension (high blood pressure in the legs) with inflammation of an unspecified lower extremity, edema (swelling resulting from… […]

• No harm, potential for more than minimal, widespreadF880Jul 8, 2026

  Based on interviews, observation, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high-contact care) while providing direct care to a Resident (R) 5 with open wounds to her left heel and left gluteal (buttock) fold. Additionally, the facility failed to ensure adequate hand hygiene during a wound measurement for R1. The facility failed to properly transport clean linen and personal linens in a sanitary manner to prevent cross contamination.Findings included:1. […]

• No harm, potential for more than minimal, widespreadF882Jul 8, 2026

  Based on interview and record review the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program (IPCP).Findings included:- On 07/08/2026 at 12:45 PM, Administrative Nurse E (Interim) revealed she could not locate her IP certificate. She reported that when she accepted the interim position, an IP certification was not mentioned, and she reported that she really had not completed much of the IP duties at the facility. Administrative Nurse E reported that she was enrolled at this time and taking courses for IP.On 07/08/2026 at 12:50 PM, Administrative Nurse E produced the antibiotic/infection control log binder. […]

• No harm, potential for more than minimal, widespreadF947Jul 8, 2026

  Five Certified Nurse Aide (CNA) staff who worked in the facility for more than 12 months were reviewed for the required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff with the required topics and no less than 12 hours per year. Findings included:- Review of CNA personnel files revealed the following:CNA N, hired on 04/04/2007, lacked the total hours calculated for the 12 hours required.Certified Medication Aide (CMA) T, hired on 12/20/2012, lacked the total hours calculated for the 12 hours required. Additionally, CMA T lacked the required education on abuse, neglect, exploitation, and dementia education. […]

• No harm, potential for more than minimal, widespreadF851Aug 28, 2024

  The facility reported a census of 43 residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS on the Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report weekend staffing for Quarter 3 of 2023 (April 1-June 3), Quarter 4 of 2023 (July 1-September 30), Quarter 1 of 2024 (October 1-December 31) and Quarter 2 of 2024 (January 1-March 31). […]