Congratulations, Sunset Manor
Coffey County Hospital’s long-term care unit, Sunset Manor in Waverly, recently received a coveted zero-deficiency rating in a combined survey by the Kansas Department on Aging & Disability Services and  Kansas Department of Health & Environment.
  • In 2011 only 4.4 percent of Kansas facilities surveyed were deficiency-free.
  • Each member of the Sunset Manor team has an integral role in meeting all 190 state regulations evaluated in the survey.
  • This remarkable achievement exemplifies the commitment of the staff at Sunset Manor to provide exceptional nursing care and the best possible quality of life for each resident.


Understanding this Honor

What organization inspects the facility and gives ratings?
In Kansas, the Department of Aging & Disability Services surveys all healthcare facilities.

Why is it so unusual for a facility to have a zero-deficiency rating?
The Centers for Medicare and Medicaid Services (CMS) has identified more than 190 deficiencies that can be cited on each survey. These deficiencies address every aspect of facility service and resident life, including:
  • employees not wearing nametags,
  • poor resident skincare,
  • dietary choices for residents,
  • access to dental care,
  • frequency of physician visits,
  • substandard food preparation and serving techniques, and
  • staff/resident interaction and relationships.
“Of the nearing 350 long-term care facilities in Kansas, only fifteen received zero-deficiency surveys last year,” explains Coffey Health System Chief Executive Officer Karen Smith. “This exceptional survey is a testament to the dedicated staff at Sunset Manor.”

In 2011, the average number of deficiencies per survey in Kansas was 14. Nationally, the average is 8.

How are deficiencies graded or assessed?

Deficiencies are ranked based on substantial compliance, noncompliance, or substandard quality of care. They are also weighted based on how wide-spread the deficiency is across the facility and how much harm or potential for harm is created.

What is considered a ‘deficiency?’

A deficiency indicates a facility’s failure to meet a federal requirement for participating in Medicare and Medicaid programs and receiving reimbursement for services provided.

Which employees have the greatest role in the zero-deficiency rating?
Just as every Sunset Manor team member plays an integral part in the care of residents, every team member also played an integral role in this tremendous success.  Beyond the walls of Sunset Manor, the Coffey Health System maintenance department also played a substantial role by meeting a host of structural and environmental regulations.

What does this mean in layman’s terms about Sunset Manor’s practices and care?
The Sunset Manor team is passionate about providing the best care possible. We focus on positive teamwork to provide exceptional care and life experiences for our residents.
In a letter of commendation, Governor Sam Brownback writes “Few people understand the many facets involved in caring for our state’s aging population.  Every deficiency-free survey encourages all Kansans whose families may need long-term care, support, and services to lead happy, healthy lives regardless of age or disability.  Your recent accomplishment is something Coffey County Hospital LTCU (Sunset Manor), and the residents who call it home, can be proud of as our state seeks continuous improvement and innovation in caring for all its citizens.”

What areas of the survey pose the biggest challenge for a facility?

It is easy to see if a lightbulb is burned out or if a floor tile is loose.  It is far more difficult to remain deficiency-free when it comes to meeting expectations of residents.  For example, residents have the right to refuse services and we are rated on our respect and preservation of those rights. On the other hand, we are also required to provide services which residents can refuse (such as bathing, repositioning for skin protection, etc.).

What should the community know about this rating?
The rating demonstrates a commitment to excellent care and enthusiasm for providing positive,
memorable life experiences for residents.  The Sunset Manor family exemplifies the core values of Coffey Health System:  respect, teamwork, professionalism, knowledge, and compassion.  They strive every day to care for residents as they would a family member.  This zero-deficiency survey is a direct result of their dedication to excellence.