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Stevens County Hospital Ltcu

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Box 758
Hugoton, KS 67951
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Details

Type of Ownership Government - County
Participates in Medicare? No
Participates in Medicaid? Yes
Certified Beds 58
Continuing Care? No
Resident Council? Yes
Family Council? No
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 08/04/2011

Date of last standard health inspection: 08/04/2011
Quality Indicator Survey No
Dates of Complaint Investigations: 12/01/2010 - 11/30/2011
Total number of Health Deficiencies for this nursing home: 9
Average number of Health Deficiencies in KS: 11
Average number of Health Deficiencies in US: 8
Range of Health Deficiencies in KS: 0 - 60
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that the nursing home area is free of dangers that cause accidents. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Isolated
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Isolated
At least once a month, have a licensed pharmacist check the drugs that each resident takes. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Isolated
Properly mark drugs and other similar products. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Isolated
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop/implement required procedures for the administration of immunizations. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Isolated
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make a complete assessment that covers all questions for areas that are listed in official regulations. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Isolated
Do a new assessment after any major change in a resident's physical or mental health. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Isolated
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Have a private telephone available for use. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Pattern
Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility. 08/04/2011 09/03/2011 Minimal harm or potential for actual harm Isolated

Inspection, 04/27/2010

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate and appropriate medical records. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Widespread
Set up or keep a group of people to review and ensure quality. 04/27/2010 08/02/2010 Minimal harm or potential for actual harm Widespread
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that the nursing home area is free of dangers that cause accidents. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Pattern
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Pattern
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and give out food in a safe and clean way. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Pattern
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. 04/27/2010 08/02/2010 Minimal harm or potential for actual harm Pattern
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. 04/27/2010 08/02/2010 Minimal harm or potential for actual harm Isolated
At least once a month, have a licensed pharmacist check the drugs that each resident takes. 04/27/2010 08/02/2010 Minimal harm or potential for actual harm Pattern
Properly mark drugs and other similar products. 04/27/2010 08/02/2010 Minimal harm or potential for actual harm Isolated
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give each resident care and services to get or keep the highest quality of life possible. 04/27/2010 08/02/2010 Minimal harm or potential for actual harm Isolated
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. 04/27/2010 08/02/2010 Minimal harm or potential for actual harm Isolated
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Isolated
Make sure that each resident's nutritional needs were met. 04/27/2010 08/02/2010 Minimal harm or potential for actual harm Isolated
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Isolated
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Pattern
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Pattern
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Pattern
Provide care in a way that keeps or builds each resident's dignity and self respect. 04/27/2010 06/10/2010 Minimal harm or potential for actual harm Isolated

Inspection, 08/06/2009

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that the nursing home area is free of dangers that cause accidents. 08/06/2009 11/05/2009 Minimal harm or potential for actual harm Isolated
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. 08/06/2009 09/17/2009 Minimal harm or potential for actual harm Widespread
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give each resident care and services to get or keep the highest quality of life possible. 08/06/2009 11/05/2009 Minimal harm or potential for actual harm Isolated
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. 08/06/2009 09/16/2009 Minimal harm or potential for actual harm Pattern
Have enough nurses to care for every resident in a way that maximizes the resident's well being. 08/06/2009 09/17/2009 Minimal harm or potential for actual harm Pattern
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. 08/06/2009 09/17/2009 Minimal harm or potential for actual harm Isolated
Let the appropriate people see and talk to each resident. 08/06/2009 11/05/2009 Minimal harm or potential for actual harm Pattern

Inspection, 02/23/2009

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide needed housekeeping and maintenance. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Pattern
Make sure that the nursing home area is free of dangers that cause accidents. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Widespread
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Pattern
Store, cook, and give out food in a safe and clean way. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Widespread
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Pattern
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Pattern
At least once a month, have a licensed pharmacist check the drugs that each resident takes. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Pattern
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the needs of each resident. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Pattern
Give each resident care and services to get or keep the highest quality of life possible. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Pattern
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Isolated
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Pattern
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Widespread
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Isolated
Give the right treatment and services to residents who have mental or social problems adjusting. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Isolated
Make sure that each resident's nutritional needs were met. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Isolated
Give each resident enough fluids to keep them healthy and prevent dehydration. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Isolated
Develop/implement required procedures for the administration of immunizations. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Pattern
Have enough nurses to care for every resident in a way that maximizes the resident's well being. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Widespread
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make a complete assessment that covers all questions for areas that are listed in official regulations. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Widespread
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Widespread
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Pattern
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep each resident's personal and medical records private and confidential. 02/23/2009 05/13/2009 Minimal harm or potential for actual harm Pattern
Allow residents to easily see the results of the nursing home's most recent survey. 02/23/2009 05/13/2009 Potential for minimal harm Widespread
Send and promptly deliver unopened mail to residents. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Pattern
Provide care in a way that keeps or builds each resident's dignity and self respect. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Isolated
Listen to the resident or family groups or act on their complaints or suggestions. 02/23/2009 03/31/2009 Minimal harm or potential for actual harm Pattern

Inspection, 12/03/2008

Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep each resident free from physical restraints, unless needed for medical treatment. 12/03/2008 01/02/2009 Minimal harm or potential for actual harm Isolated
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give the right treatment and services to residents who have mental or social problems adjusting. 12/03/2008 01/02/2009 Actual harm Isolated

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in KS Golden Living Center, Asheville
RN Staff Only1 N/A N/A 4 out of 5 stars
Total Number of Residents 86 54 51
Total, Licensed Nurse Staff Hours
per Resident per Day 		1 hour 29 minutes 1 hour 20 minutes 55 minutes
RN Hours
per Resident per Day 		40 minutes 40 minutes 36 minutes
LPN/LVN Hours
per Resident per Day 		49 minutes 39 minutes 19 minutes
CNA Hours
per Resident per Day 		2 hours 25 minutes 2 hours 34 minutes 2 hours 50 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Percent of high-risk long-stay residents who have pressure sores 5%
Percent of long-stay residents given influenza vaccination during the flu season 90+%
Percent of long-stay residents who are more depressed or anxious 6%
Percent of long-stay residents who had a urinary tract infection 10%
Percent of long-stay residents who have moderate to severe pain 5%
Percent of long-stay residents who have/had a catheter inserted and left in their bladder 3%
Percent of long-stay residents who spend most of their time in bed or in a chair 0%
Percent of long-stay residents who were assessed and given pneumococcal vaccination 77%
Percent of long-stay residents who were physically restrained 0%
Percent of long-stay residents whose ability to move about in and around their room got worse 8%
Percent of long-stay residents whose need for help with daily activities has increased 13%
Percent of low-risk long-stay residents who have pressure sores 6%
Percent of low-risk long-stay residents who lose control of their bowels or bladder 49%

Short-Term Residents

Percent of long-stay residents who lose too much weight 6%
Percent of short-stay residents given influenza vaccination during the flu season Not Available
Percent of short-stay residents who had moderate to severe pain Not Available
Percent of short-stay residents who have delirium Not Available
Percent of short-stay residents who have pressure sores Not Available
Percent of short-stay residents who were assessed and given pneumococcal vaccination Not Available

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 02/24/2011

Automatic Sprinkler Systems in all required areas partially sprinklered
Date of last standard fire safety inspection: 02/24/2011
Dates of Complaint Investigations: 12/01/2010 - 11/30/2011
Total number of Fire Safety Deficiencies for this nursing home: 1
Average number of Fire Safety Deficiencies in KS: 1
Average number of Fire Safety Deficiencies in US: 4
Range of Fire Safety Deficiencies in KS: 0 - 1
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
proper medical gas storage and administration areas. 02/24/2011 02/28/2011 Minimal harm or potential for actual harm Isolated

Inspection, 02/15/2010

Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
properly installed electrical wiring and equipment. 02/15/2010 03/17/2010 Minimal harm or potential for actual harm Isolated
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
exits that are free from obstructions and can be used at all times. 02/15/2010 03/17/2010 Minimal harm or potential for actual harm Pattern
restrictions on the use of flammable curtains. 02/15/2010 03/17/2010 Minimal harm or potential for actual harm Isolated
Illumination and Emergency Power Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
emergency lighting that can last at least 1 1/2 hours. 02/15/2010 03/17/2010 Minimal harm or potential for actual harm Isolated
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
proper medical gas storage and administration areas. 02/15/2010 03/17/2010 Minimal harm or potential for actual harm Isolated

Inspection, 01/05/2009

Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
corridor and hallway doors that block smoke. 01/05/2009 01/05/2009 Minimal harm or potential for actual harm Isolated
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
weekly inspections and monthly testing of generators. 01/05/2009 02/04/2009 Minimal harm or potential for actual harm Widespread
properly installed electrical wiring and equipment. 01/05/2009 02/04/2009 Minimal harm or potential for actual harm Isolated
Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
record of quarterly fire drills for each shift under varying conditions. 01/05/2009 02/04/2009 Minimal harm or potential for actual harm Isolated
Illumination and Emergency Power Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
proper backup exit lighting. 01/05/2009 01/12/2009 Minimal harm or potential for actual harm Isolated
emergency lighting that can last at least 1 1/2 hours. 01/05/2009 01/12/2009 Minimal harm or potential for actual harm Isolated