Diversicare Of Haysville
Inspection history, citations, penalties and survey trends for this long-term care facility in Haysville, Kansas.
- Location
- 215 N Lamar Avenue, Haysville, Kansas 67060
- CMS Provider Number
- 175133
- Inspections on file
- 23
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Diversicare Of Haysville during CMS and state inspections, most recent first.
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 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.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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