Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Diversicare Of Haysville during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment, falls, and unsteady gait was not accurately identified as an elopement risk, and the care plan lacked wandering/elopement interventions. Staff had documented episodes of confusion and wandering, but the elopement assessment was marked no. The resident later exited the building and was found outside near roads and other hazards in rainy weather; staff brought her back inside, and the main door was later found not to fully latch.
A facility failed to keep residents free from misappropriation when an LPN diverted 187 opioid tablets from the narcotics supply and removed or mishandled controlled-substance records. Residents with chronic pain, fractures, spinal conditions, gout, and neuropathy had active opioid orders and received pain meds, but narcotic cards and count sheets went missing, signatures on reconciliation logs were not reliable, and documentation showed falsified initials and undocumented removal of narcotic cards.
A facility failed to ensure accurate controlled substance reconciliation when a narcotic sheet was missing from a medication cart and an audit found 187 missing opioid tablets from the cart over several months. A later review of the controlled substance shift count sheet also showed missing signatures for multiple shift counts, and an admin nurse stated she received notice of the missing signatures but took no action at the time.
A nurse performed wound care on a resident without wearing a gown as required by Enhanced Barrier Precautions and did not consistently perform hand hygiene between glove changes. The nurse also transitioned between wounds without completing care on one before starting another, contrary to facility policy. These actions were confirmed by staff interviews and review of facility infection control policies.
Staff did not consistently secure medication carts or properly account for controlled substances, resulting in missing medication cards and instances where medications were left unattended in resident rooms. Interviews confirmed staff were aware of expectations for medication security and documentation, but these practices were not followed, and the facility could not provide a policy on competent staffing.
The facility did not accurately report weekend staffing hours in its PBJ submission, omitting hours worked by administrative nurses and weekend managers who filled in during staff call-offs, particularly during an influenza outbreak. This resulted in incomplete staffing data being submitted to the federal regulatory agency.
Several residents with severe cognitive and physical impairments were left exposed or inadequately covered during care and meals, and staff did not follow expected practices such as sitting next to residents during feeding assistance. Staff interviews confirmed these actions were not in line with facility policy to ensure resident dignity and privacy.
Surveyors found that medications, oxygen cylinders, and chemical agents were left unsecured in areas accessible to cognitively impaired, independently mobile residents, and that a resident with severe cognitive and mobility impairments was not consistently kept in a low bed position as care-planned. These deficiencies occurred despite facility policies requiring safe storage and adherence to fall prevention interventions.
Surveyors found that multiple medication carts were left unlocked and unattended, containing various medications including undated insulin pens, and that medication and narcotic keys were left in the carts. Staff interviews confirmed that carts should be locked and medications labeled, but the facility could not provide a relevant storage policy.
Surveyors found that a resident's Foley catheter tubing and urinary bag were on the floor, another resident's nasal oxygen tubing was not stored properly, a CNA failed to sanitize a Hoyer lift between uses, and clean linen was transported uncovered through hallways. Staff interviews confirmed these actions were not in line with facility infection control policies.
A resident with significant physical and cognitive care needs was found with medication cups containing multiple pills left at her bedside without a physician order or assessment for self-administration. Staff confirmed that required protocols for self-administration were not followed, and the facility lacked a policy on resident self-medication administration.
Two residents with severe cognitive and physical impairments did not have appropriate access to call lights or alternative communication methods as required by their care plans. One resident, unable to use a standard push-button call light, was not provided with a soft-touch device, while another had her call light out of reach on multiple occasions. Staff confirmed the expectation for call lights to be accessible, but this was not consistently ensured, and the facility could not provide a relevant policy.
Residents were unable to access their trust account funds 24 hours a day, seven days a week, as withdrawals were limited to a specific weekday hour through administrative staff, with only small amounts available on weekends from nursing staff. This practice was confirmed by resident council members, administrative staff, and nursing staff, and was inconsistent with the facility's stated policy for resident fund access.
A resident with multiple neurological conditions and moderate cognitive impairment had their prescribed Oxycodone misappropriated from the medication cart when a nurse failed to log the medication into the narcotic inventory. The missing medication was discovered during a review of narcotic counts, and further investigation revealed additional controlled substance cards were also missing. Required documentation and shift count procedures were not followed, resulting in the loss of the resident's medication.
A resident with multiple neurological diagnoses and moderate cognitive impairment was prescribed oxycodone, but the medication was not properly logged into the narcotic inventory by the receiving nurse. When the missing medication was discovered, staff confirmed that required narcotic count procedures were not followed, and additional controlled substance cards were also missing. The facility did not report the misappropriation to the state agency within the required timeframe, as required by policy.
The facility did not consistently provide scheduled weekend activities, especially on Sundays, to promote socialization among residents. Although church services were held and some activities were listed on the calendar, residents and staff reported that these activities were not regularly conducted due to staff being too busy, resulting in residents often remaining in their rooms with limited engagement.
A resident with CHF, COPD, and edema did not have daily weights consistently obtained and recorded as ordered by the physician. Staff interviews confirmed that all were responsible for obtaining and documenting weights, and that the physician should be notified if weights were missed, but there was no evidence of such notifications. The facility could not provide a related quality of care policy.
A resident with dementia and severe cognitive impairment did not receive appropriate dementia-related care and services. The care plan lacked interventions for behavioral symptoms and care refusals, and staff did not consistently document or implement alternative strategies when the resident refused bathing and grooming. Observations and records showed repeated refusals and unmet care needs, with staff responses limited to re-offering care or reporting refusals, contrary to the facility's dementia care policy.
The facility did not ensure that a licensed pharmacist identified and reported medication irregularities, nor that physicians addressed pharmacist recommendations for several residents. One resident's psychotropic medication regimen lacked required documentation and physician review, another resident's oxygen saturation monitoring was not documented as ordered, and a third resident's medication orders lacked necessary dosing instructions and monitoring parameters. These deficiencies were confirmed through record review and staff interviews.
Two residents did not have required monitoring and documentation for oxygen saturation, pulse, and blood pressure as ordered for their medications, and one resident had a topical medication order without a specified dosage amount. These deficiencies resulted in a lack of compliance with physician orders and placed the residents at risk for unnecessary medication administration and related complications.
Two residents were not properly offered or administered the PCV20 pneumococcal vaccine as required. One resident's record lacked documentation of the vaccine being offered, declined, or contraindicated, while another resident gave consent but did not receive the vaccine. Staff interviews indicated unclear responsibility for immunization tracking and administration.
Failure to Identify Elopement Risk and Supervise a Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately identify Resident 1’s elopement risk and failed to provide adequate supervision to prevent the resident from leaving the building. Resident 1 had diagnoses including dementia, muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination, repeated falls, and cognitive communication deficit. The resident’s MDS documented a BIMS score of 10, indicating moderate cognitive impairment, and also noted use of a walker, a history of multiple falls, and at least one fall with injury. The care plan addressed falls and impaired cognition, but it did not include interventions related to wandering or elopement risk. Prior to the event, the record documented episodes of increased confusion and wandering. A general note documented the resident wandering the hall at night and needing redirection back to her room, and a weekly nurse’s note documented similar nighttime wandering and redirection. On the day of the event, staff observed the resident sitting by a window drinking coffee and watching the rain. About 30 minutes later, residents alerted an LPN that the resident was outside on the east side of the building. The LPN brought the resident back inside and assisted her into dry clothes. The resident was found outside in rainy weather near roads with posted speeds up to 35 miles per hour, with additional hazards described in the surrounding area including a leaning fence, loose boards, nails on the ground, and a wooded tree line. The resident’s elopement risk had been inaccurately assessed earlier that month. During a Health Status Evaluation, the elopement section was marked “no,” and the remaining questions were not completed. After the resident was found outside, staff obtained a physician order and placed a Wanderguard on the resident. Witness statements described the resident as wandering, focused on getting to her car, and being redirected to sit in the common area. Staff also reported that the main door had been held open earlier and that the door was later found not to be fully latching. Maintenance later adjusted the door so it would close and latch properly. The facility determined the resident had been outside for an unknown amount of time and was wet when found.
Misappropriation of Controlled Substances Through Missing Narcotic Records and Diversion
Penalty
Summary
The facility failed to ensure residents remained free from misappropriation when staff diverted 187 hydrocodone, oxycodone, and/or Percocet tablets from the controlled substance supply between 02/01/2025 and 10/30/2025. The affected residents included multiple individuals with documented pain-related diagnoses such as chronic pain, spinal stenosis, polyneuropathy, rheumatoid arthritis, fractures, gout, and other conditions requiring opioid analgesics. Their EMRs and MARs showed active physician orders for hydrocodone, oxycodone, hydrocodone-acetaminophen, and Percocet, and documentation indicated the medications were being administered for assessed pain. The investigation identified that LN I was responsible for the missing narcotics from hall five. Witness statements documented that narcotic sheets and cards were removed from the medication cart and that narcotic reconciliation paperwork could not be located afterward. One statement described LN I placing a narcotics paper in the back of the narcotics book and leaving it there for another nurse to verify and remove, but the paper was later missing. Another statement described a narcotic card and count sheet being removed after a resident requested pain medication, followed by the next morning’s inability to find the narcotic sheet that had been removed. Additional witness statements indicated that signatures on controlled substance reconciliation records were not remembered or recognized by the staff members whose initials appeared on them. The facility’s investigation documented that three narcotic cards were removed from the reconciliation log without documentation and that falsification of staff initials occurred when narcotic logs were removed. The audit identified 187 opioid tablets missing from 08/22/2025 through 10/27/2025, and LN I was working during the periods when the narcotics were missing. The report also stated that no narcotic record was turned into medical records for that date, and that the missing narcotics were tied to the removal of a narcotic card that was not empty when a new card arrived from the pharmacy.
Missing Controlled Substance Count Signatures and Unreconciled Opioid Tablets
Penalty
Summary
The facility failed to ensure an accurate reconciliation of controlled medications. A facility-reported incident dated 10/27/2025 documented that one narcotic sheet was missing from the hall five medication cart. The facility then completed a medication audit covering 02/01/2025 through 10/30/2025 and found that from 08/22/2025 to 10/27/2025, a total of 187 opioid tablets were missing from the hall five medication cart. On 06/16/2026, a review of the June 2026 Controlled Substance Shift Count Sheet showed missing signatures for the off-going shift on 06/14/2026 at 06:00 AM, the oncoming shift on 06/15/2026 at 10:00 PM, and the off-going shift on 06/16/2026 at 06:00 AM. CMA R stated that two staff counted the controlled medications every time they changed shifts and both signed the shift count sheet for verification. Administrative Nurse D stated she received an email on 06/15/2026 about staff not signing the count sheet on 06/14/2026 and did nothing because she thought it had been taken care of. She later stated that when signatures were missing, she would notify the nurse to return and verify the count and sign the sheet.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a licensed nurse performed wound care on a resident without adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. During the wound care procedure, the nurse donned gloves but failed to wear a gown as required for EBP. The nurse also did not consistently perform hand hygiene between glove changes, specifically after removing gloves and before donning new ones during the care of multiple wounds. The nurse transitioned between treating the resident's leg wound and coccyx wound without completing care on one wound before moving to the next, contrary to facility expectations and infection control best practices. Interviews with nursing staff and administrative nurses confirmed that the facility's policy required the use of both gown and gloves for wound care under EBP, completion of care on one wound before addressing another, and hand hygiene with every glove change. The facility's infection control policy also documented that all team members would be trained on these practices. The observed failure to follow these protocols during wound care placed the resident at risk for wound infection and related complications.
Failure to Ensure Competent Medication Management by Staff
Penalty
Summary
Staff failed to maintain proper handling, storage, and administration of medications, including controlled substances. A controlled substance pill card containing oxycodone prescribed to a resident was reported missing, along with its count sheet, and the facility was unable to determine when the card was last verified or seen by staff. Additionally, 11 other medication cards were found missing from the medication destruction/disposal box. During facility inspections, medication carts were repeatedly observed left unlocked and unattended in various locations, with prescription medications and ointments accessible. In one instance, a resident's morning medications were left unattended on her bedside table while she slept. Interviews with staff confirmed that medication carts were expected to be locked when not in use and that medications should not be left unsupervised in resident rooms. Staff also stated that narcotic counts were to be completed at each shift change with two nurses signing off. Despite these expectations, the facility was unable to provide a policy related to competent staffing when requested. These failures demonstrated that staff did not possess or consistently apply the necessary skills and knowledge to safely manage medications.
Failure to Accurately Report Weekend Staffing Hours in PBJ Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) by not including all weekend staffing coverage hours. During the review period, the facility triggered for excessively low weekend staffing, and interviews with the Resident Council and staff confirmed that weekend staffing frequently changed due to call-offs. When call-offs occurred, weekend managers or administrative nurses would fill in the gaps, but their hours were not included in the PBJ submission. A review of the facility's working schedule, time sheets, and posted staffing hours showed no documented gaps, but administrative nurse coverage was used during call-offs. An administrative nurse confirmed that nurse managers worked extra shifts during a recent influenza outbreak, but their time was not reported in the PBJ data. The facility was unable to provide a policy related to staffing or PBJ reporting when requested.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
Surveyors observed multiple instances where staff failed to maintain resident dignity for several severely cognitively and physically impaired residents. One resident was left sitting on her bed with only underwear on her lower half, exposed while eating breakfast and falling asleep. Another resident was seen in bed with only a sheet covering his groin area and his door fully open, allowing staff and other residents to see inside. A third resident was assisted with feeding in the dining room while the staff member stood the entire time, rather than sitting next to her as expected. A fourth resident was found lying in bed facing the door, with her gown exposing her upper right side up to her chest. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that staff were expected to cover residents to prevent exposure and embarrassment, and to sit next to residents while providing feeding assistance. The facility's policy required ensuring a dignified existence and a clean, comfortable, and safe environment for all residents. These observations and staff statements demonstrated that the facility failed to provide a dignified care environment for the affected residents.
Unsafe Storage of Hazardous Items and Failure to Maintain Bed Safety Interventions
Penalty
Summary
Surveyors identified multiple deficiencies related to the unsafe storage of medications, pressurized oxygen cylinders, and chemical agents in areas accessible to cognitively impaired, independently mobile residents. During facility walkthroughs, an unlocked supplemental oxygen storage closet containing 79 fully compressed oxygen cylinders was found, and staff confirmed the closet should have been locked. Additionally, a shower room was found propped open with an unsecured bottle of multi-surface disinfectant, and several medication carts were left unlocked and unattended in various hallways and rooms, containing unsecured medications and prescription ointments. On two occasions, a resident's morning medications were left unattended on her bedside table while she slept. Staff interviews confirmed that facility policy required these items to be secured when not in use or unsupervised, but this was not consistently followed. Another deficiency involved the failure to maintain a resident's bed at the care-planned safe height. The resident in question had diagnoses of hemiparesis, hemiplegia, and cerebral infarction, resulting in severely impaired cognition and dependence on staff for all activities of daily living. Her care plan and Kardex directed staff to keep her bed in the lowest position for safety. However, observations on multiple occasions found her bed elevated several feet off the floor while she was in bed, contrary to her care plan interventions. Staff interviews confirmed that fall interventions were documented and expected to be followed, but the bed was not consistently kept in the lowest position. Facility policies required the safe storage of medications, oxygen cylinders, and chemicals, as well as adherence to individualized fall prevention interventions. The observed failures to secure hazardous items and to maintain the resident's bed at the prescribed height constituted deficiencies that placed residents, particularly those with cognitive impairments and mobility limitations, at risk for preventable accidents and injuries.
Failure to Properly Store and Label Medications in Medication Carts
Penalty
Summary
Surveyors observed that medications were not properly stored or labeled in several medication carts within the facility. Specifically, three out of five medication carts were found unlocked and unattended in various locations, including hallways and a resident's quiet room. These carts contained various medications such as insulin pens, scheduled medications, narcotics, nasal sprays, eye drops, skin creams, enemas, and pain relief creams. Additionally, five opened insulin pens were found undated in one cart, and medication and narcotic keys were left in the carts while unattended. Interviews with staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that medication carts should always be locked when unattended and that keys should not be left in the locks. Staff also stated that insulin pens should be labeled and dated at the time of first administration. The facility was unable to provide a policy related to medication storage. These findings demonstrate a failure to properly store and label medications as required.
Infection Control Lapses in Equipment and Linen Handling
Penalty
Summary
Surveyors identified multiple infection control deficiencies during their inspection. One resident's Foley catheter tubing and urinary bag were found lying directly on the floor, despite being covered with a privacy bag. Another resident's nasal oxygen tubing was observed wrapped around the back of a wheelchair handle and not stored in a sanitary manner. Additionally, after transferring a resident with a Hoyer lift, a CNA failed to sanitize the lift before moving it to another area. Clean linen was also observed being transported through hallways in an uncovered cart, exposing it to potential contamination. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that facility policy requires oxygen tubing and equipment to be stored in clean bags, shared equipment like the Hoyer lift to be sanitized between uses, and clean linen to be covered when transported. Staff also acknowledged that Foley catheter bags and tubing should not be on the floor. These observations and staff statements indicate that established infection control policies were not consistently followed, resulting in practices that could contribute to the transmission of infectious diseases.
Failure to Ensure Safe and Appropriate Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including blindness in one eye, paraparesis, muscle weakness, and a cognitive communication deficit was observed to have medication cups with multiple pills left on her bedside table on multiple occasions. The resident's medical record indicated she required assistance with all daily cares, was dependent on staff for transfers and bed mobility, and needed substantial to maximum assistance with upper body dressing. Despite these needs, there was no physician order or assessment for self-administration of medication documented in her electronic medical record. Interviews with facility staff confirmed that a physician order and a nurse's assessment are required for a resident to self-administer medications, and that the resident in question did not have either. Staff also stated that medications should not be left at the bedside without proper authorization. The facility was unable to provide a policy regarding resident self-medication administration, and the resident's care plan specified that staff would administer her medications as ordered.
Failure to Ensure Call Light Accessibility for Residents with Impairments
Penalty
Summary
The facility failed to ensure that two residents with significant cognitive and physical impairments had appropriate access to call lights or other methods to communicate their needs. One resident, who had diagnoses including dysphagia, muscle weakness, intellectual disabilities, and severe cognitive impairment, was care planned to use a soft-touch call light due to her inability to operate a standard push-button device. Despite this, observations revealed that only a push-button call light was available in her room, and she had difficulty holding and using it. Staff interviews confirmed that a soft-touch call light was indicated for her, but it was not in place at the time of inspection. Another resident, with diagnoses such as major depressive disorder, anxiety, hypertension, dementia, and cognitive communication deficits, was also found without her call light within reach on multiple occasions. Her care plan specified that staff should ensure her call light was accessible and encourage its use for assistance. However, during observations, her call light was found wrapped with another and dangling on the floor, out of her reach, both in the morning and on subsequent days. Staff interviews confirmed that all residents should have their call lights within reach, but this was not maintained for this resident. The facility was unable to provide a policy related to accommodation of needs or call lights when requested. The lack of appropriate call light access for these residents, as observed and confirmed by staff, constituted a failure to reasonably accommodate their needs and preferences, as required by their care plans and assessments.
Failure to Provide 24/7 Access to Resident Trust Funds
Penalty
Summary
The facility failed to ensure that residents had 24/7 access to their personal funds held in trust accounts. Multiple residents reported that they could only withdraw money from their trust accounts through administrative staff during a limited window, specifically Monday through Friday from 11:00 AM to 12:00 PM. Administrative staff confirmed that this schedule was set to limit the frequency of resident requests. On weekends, only a small amount of cash was available, kept in an envelope on a specific hall cart, and residents could request this from the nurse on duty. Staff interviews confirmed that access to funds outside of the designated weekday hour was limited to small amounts and only on one hall. The facility's policy stated that at least $200 in petty cash should be available daily for resident withdrawals, but in practice, access was restricted both by time and by the amount available on weekends. Residents were informed of these limitations upon admission. The sample included five residents reviewed for resident funds, and the deficiency was identified through interviews with residents, administrative staff, and nursing staff, as well as review of facility policy and observation.
Misappropriation of Controlled Medication from Medication Cart
Penalty
Summary
A deficiency occurred when a resident's controlled pain medication, specifically Oxycodone, was misappropriated from the facility's medication cart. The resident had a history of hemiparesis, Parkinson's disease, and dementia, with moderately impaired cognition as indicated by a BIMS score of ten. The medication was prescribed to be administered as needed for pain, and the resident was receiving opioids during the observation period. The incident was identified when the Director of Clinical Operations and nursing staff discovered that the narcotic card for the resident's medication was missing and had not been properly logged into the narcotic inventory count by the receiving nurse. Further review revealed that the narcotic count sheet was present and reconciled, but the medication itself was missing. Additional investigation found that other controlled substance cards were also missing from the medication box designated for destruction, and the facility was unable to determine the alleged perpetrator responsible for the misappropriation. Interviews with staff confirmed that it was facility policy to count narcotics at each shift change and to document any new narcotic cards added to the count. However, the required documentation and procedures were not followed in this instance, resulting in the misappropriation of the resident's medication. The facility's policy also required internal investigation and reporting of such incidents, but the state was not notified as the facility did not initially consider the event to be abuse.
Failure to Timely Report Misappropriation of Controlled Substance
Penalty
Summary
The facility failed to submit a full investigation of a reportable occurrence involving the misappropriation of a controlled substance prescribed to a resident within the required twenty-four-hour timeframe to the appropriate state agency. The resident in question had diagnoses including hemiparesis/hemiplegia, Parkinson's disease, and dementia, with a moderately impaired cognitive status as indicated by a BIMS score of ten. The resident was prescribed oxycodone for pain management, and pharmacy records showed that 30 tablets were delivered. However, the receiving nurse did not log the medication into the narcotic inventory count on the day of delivery. The issue was discovered when the Assistant Director of Nursing was notified of missing narcotics, prompting verification of medication records and reconciliation of the narcotic count. Further review revealed that the narcotic count sheet was present, but the medication had not been properly logged, and additional controlled substance cards were also found missing from the medication box designated for destruction. Staff interviews confirmed that the facility's policy required narcotics to be counted and documented at each shift change, but this process was not followed in this instance. Despite identifying the missing medication and confirming that the resident did not miss any doses, the facility did not report the incident to the state agency within the required timeframe, as they did not believe abuse was involved and were unable to identify a perpetrator. The facility's own policy required internal investigation and reporting of any alleged violation of abuse, neglect, exploitation, or misappropriation of resident property to the enforcement agency, but this was not adhered to in this case.
Inconsistent Weekend Activities for Residents
Penalty
Summary
The facility failed to provide consistent weekend activities, particularly on Sundays, to promote socialization among residents. A review of the activity calendars for January, February, and March 2025 showed that while church services were scheduled every Sunday, additional activities such as movie nights and game nights were only sporadically listed. Resident Council members reported that, despite activities being listed on the calendar, there were not many actual activities on Sundays, and residents often stayed in their rooms watching TV. They also noted that staff were too busy to lead the scheduled activities, resulting in long and uneventful weekends. Interviews with staff and administration confirmed that the activities staff worked only Monday through Friday, and that weekend activities were supposed to be led by volunteers or nursing staff. However, it was acknowledged that these activities were not consistently provided. The facility's own policy required an ongoing program of group, individual, and independent activities to meet residents' interests and support their well-being, but this was not consistently implemented on weekends, particularly Sundays.
Failure to Follow Physician's Order for Daily Weights in CHF Resident
Penalty
Summary
The facility failed to follow a physician's order for daily weights for a resident diagnosed with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and edema. The resident's care plan required nursing staff to monitor weight as ordered, and the physician's order specified daily weights using a Hoyer lift. Review of the Medication Administration Record (MAR) over a 37-day period revealed multiple instances where the resident's weight was not measured or recorded, including days marked as missed, refused, asleep, on hold, or with instructions to see progress notes. There was no documentation that the physician was notified when daily weights were not obtained, as required by facility protocol. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that all staff were responsible for obtaining daily weights and that the nurse was expected to document weights in the MAR and notify the physician if weights were missed. The facility was unable to provide a policy related to quality of care. These actions and omissions resulted in a failure to provide appropriate treatment and care according to physician orders and the resident's care plan.
Failure to Provide Dementia-Related Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia-related care services for a resident diagnosed with dementia and severe cognitive impairment. The resident's care plan addressed her self-care deficits and need for assistance with daily activities but did not include interventions for dementia-related behaviors or care refusals. Documentation showed repeated instances where the resident refused bathing and grooming, yet there was no evidence of alternative interventions or rationales being offered or documented. Staff interviews confirmed that refusals were common, but responses were limited to re-offering care or reporting refusals, without individualized strategies or consistent documentation of attempted interventions. Observations revealed the resident often appeared with uncombed, greasy hair and was unsure about her last bathing or grooming. Progress notes documented episodes of confusion, agitation, and behaviors such as grabbing items, attempting to leave, and throwing objects, with staff frequently unable to redirect her and no further interventions noted. The facility's own dementia care policy required staff to re-approach residents after refusals and address behaviors of distress, but these practices were not consistently followed or documented for this resident.
Failure to Ensure Effective Drug Regimen Review and Physician Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed an effective monthly drug regimen review and that physicians addressed consultant pharmacist (CP) recommendations for multiple residents. For one resident with diagnoses including depression, anxiety, and congestive heart failure, the medical record lacked documentation of a gradual dose reduction (GDR) attempt for psychotropic medication, and there was no evidence that the physician reviewed or addressed the CP's recommendations regarding as-needed psychotropic medication. The monthly medication reviews were left unaddressed and unsigned, and the facility could not provide evidence that the physician had reviewed the recommendations as required by policy. Another resident with multiple chronic conditions, including hypertension, COPD, heart failure, diabetes, and mental health disorders, had a physician order to maintain oxygen saturation above 90%. However, after a change in the order, staff failed to monitor and document oxygen saturation as required, with no documentation on multiple opportunities. The CP did not identify or report this lack of monitoring and documentation, and the care plan did not direct staff to maintain oxygen saturation above the specified threshold. A third resident with Parkinson's disease, CHF, dementia, and osteoporosis had medication orders for digoxin and metoprolol that lacked required parameters for pulse and blood pressure monitoring prior to administration. Additionally, an order for topical diclofenac gel lacked a specified dosage amount. The CP failed to identify and report these irregularities, and staff did not obtain or document the necessary vital signs before administering these medications. These deficiencies were confirmed through record review and staff interviews, and the facility's policies required such irregularities to be identified and reported by the CP.
Failure to Monitor and Document Medication Parameters and Oxygen Saturation
Penalty
Summary
The facility failed to ensure that a resident's oxygen saturation was monitored and documented as ordered by the physician. The resident, who had multiple diagnoses including hypertension, COPD, heart failure, diabetes, bipolar disorder, and schizoaffective disorder, required oxygen therapy with a specific order to maintain oxygen saturation above 90%. Despite this, staff did not monitor or document the resident's oxygen saturation on any of the required opportunities in both February and March, as evidenced by a review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Interviews with staff confirmed that the electronic medical record (EMR) was not set up to prompt for oxygen saturation documentation, and the care plan lacked specific instructions regarding maintaining oxygen saturation levels. Another resident with diagnoses including Parkinson's disease, congestive heart failure, dementia, and osteoporosis was not properly monitored before administration of certain cardiac medications. The resident had physician orders for digoxin and metoprolol, but these orders lacked parameters for pulse and blood pressure monitoring prior to administration. Review of the MAR and TAR showed that staff did not obtain or document pulse readings before administering digoxin, nor did they monitor or document blood pressure and pulse before administering metoprolol. Additionally, a topical medication order for diclofenac gel lacked a specified dosage amount. Staff interviews confirmed that these monitoring steps and dosage specifications were expected but not followed. The facility did not provide a policy regarding unnecessary medications when requested. The lack of monitoring and documentation for oxygen saturation, pulse, and blood pressure, as well as incomplete medication orders, resulted in deficiencies related to the administration of unnecessary medications and placed the residents at risk for medication-related complications.
Failure to Offer, Document, and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to properly offer, document, and administer pneumococcal vaccinations in accordance with its own policy and CDC guidelines. For one resident, there was no documentation that the PCV20 vaccine was offered, declined, previously administered, or that a physician-documented contraindication existed. For another resident, although consent for the PCV20 vaccine was obtained, there was no documentation that the vaccine was actually administered. Interviews with facility staff revealed that while residents were asked about their immunization history at admission, there was a lack of clarity regarding responsibility for tracking and administering immunizations. The Infection Preventionist was identified as responsible for these tasks, but the process failed, resulting in missed vaccination and documentation for the affected residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 287 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Haysville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westview Of Derby Rehabilitation & Health Care Cen | 5.2 mi | ★★★★★ | 0 | 0 |
| Homestead Health Center | 6.2 mi | ★★★★★ | 10 | 0 |
| Medicalodges Wichita | 6.4 mi | ★★★★★ | 21 | 0 |
| Derby Health & Rehabilitation, Llc | 6.5 mi | ★★★★★ | 2 | 0 |
| Mount St Mary | 8.1 mi | ★★★★★ | 0 | 0 |
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