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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Via Christi Village Hays Ks Llc during CMS and state inspections, most recent first.
Failure to Provide Ordered Restorative Therapy: Multiple residents with diagnoses such as dementia, CVA, Parkinson’s disease, weakness, and impaired mobility had care plans directing ROM and restorative programs, but EMR and MDS review showed limited or inconsistent restorative therapy compared with the ordered frequency. Staff interviews confirmed CNAs were responsible for restorative tasks, but they reported insufficient staffing and time to complete them, and no restorative therapy was observed over two consecutive days.
Insufficient staffing resulted in missed restorative nursing services for multiple residents whose care plans required regular ROM, band exercises, and NuStep sessions. EMR review showed each resident received far fewer restorative sessions than ordered, and staff, including CNAs and LNs, stated there was not enough time or coverage to complete the tasks consistently, with no accountability when nurses were off the floor.
Failure to Complete Accurate Pre-Hire Background Check: The facility did not complete an accurate pre-employment criminal background check for a dietary employee before hire. The personnel file lacked evidence of a proper background check, and a later check using the correct name showed convictions for crimes against a person. Administrative staff stated the original check had been done with the employee’s name spelled incorrectly, resulting in a clear report.
Failure to Ensure CNA Competency in Resident Care and Dignity: A CNA left a resident with muscular dystrophy and stroke deficits alone during bedtime care after starting a full-lift transfer, leaving her without her call light and unable to get help. In a separate event, two CNAs observed another resident’s urinary catheter bag exposed in the dining room and did nothing to cover it or preserve dignity. The facility could not produce competency records for the involved CNA and several others.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Staff oversight and environmental safety measures were insufficient to protect residents from potential harm.
The facility did not employ a full-time Certified Dietary Manager to supervise meal preparation and kitchen sanitation. Instead, a dietary staff member without certification, but enrolled in a certification course, managed the kitchen with weekly oversight from a Registered Dietitian. Administrative staff confirmed the absence of a certified manager, contrary to facility policy.
Surveyors found that kitchen drawers containing scoops and ladles had food crumbs and dried liquid spills, which was confirmed by dietary staff. The facility's policy required a posted cleaning schedule and staff accountability for cleaning tasks, but these standards were not met.
The facility's QAA program did not effectively identify or address numerous care issues, including undignified dining experiences, lack of medication management, failure to update care plans, inadequate wound and foot care, improper transfer procedures leading to injury, insufficient nutritional interventions, poor communication about wound care, missed CNA in-service training, and lack of follow-up on dental needs. Additional problems included pharmacy oversight lapses, improper medication labeling, expired medications, lack of a Certified Dietary Manager, unsanitary kitchen conditions, and inadequate infection control practices.
Two nurse aides did not complete the required 12 hours of annual in-service training, with one completing only 6.5 hours and another 7.5 hours. This deficiency was identified through record review and staff interviews, and was attributed in part to a recent change in facility ownership and reliance on previous management for training records.
Surveyors found that staff failed to use appropriate PPE while handling soiled laundry and did not consistently implement Enhanced Barrier Precautions during high-contact care and wound care for two residents with chronic wounds and skin breakdown. Staff were observed performing care activities without required gowns and gloves, and there was a lack of clear care plan direction and signage for EBP, resulting in inconsistent infection control practices.
A resident who required assistance with eating was repeatedly left waiting at the dining table while two other residents at the same table were served and finished their meals. Staff delayed serving and assisting the resident until after the others had eaten, citing competing care priorities. This resulted in the resident observing others eat while she waited for her own meal, contrary to facility policy on resident dignity.
A resident with multiple diagnoses, including anxiety and dementia, continued to receive buspirone for anxiety and depression without a documented gradual dose reduction (GDR) or physician rationale for ongoing use. Despite facility policy and care plan directives, neither the pharmacy nor the physician initiated or documented a GDR, and the medication regimen was continued without evidence of review for necessity.
The facility did not provide required bed-hold notifications to two residents or their representatives during hospital transfers, and failed to notify the ombudsman for one resident's discharges. One resident with multiple medical conditions was transferred without documentation of a bed-hold notice, and another resident's representative did not receive a written bed-hold signature or ombudsman notification, despite facility policy requiring these actions.
Two residents' care plans were not updated to reflect current physician orders and care needs, including the use of oxygen therapy and a leg immobilizer. One resident developed skin breakdown under a leg immobilizer without proper care plan guidance for staff, while another received oxygen therapy that was not documented in the care plan. Staff were unaware of these omissions, and the facility's policy requiring timely care plan updates was not followed.
The facility did not ensure that a resident with pressure ulcers received proper care to promote healing, and failed to implement adequate preventive measures to stop new ulcers from developing.
A resident with significant physical impairments and multiple diagnoses was found to have long, curling toenails due to a lack of routine foot care. Staff interviews revealed confusion over who was responsible for nail care, and the facility's policy requiring regular nail trimming was not followed, resulting in the resident not receiving appropriate foot care.
A deficiency was cited for not providing enough food and fluids to maintain a resident's health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not include further details about the circumstances or the resident's condition.
A resident with chronic respiratory failure and neurological impairment had oxygen, nebulizer, and CPAP equipment left unwrapped and not stored in bags as required by facility policy. Staff confirmed that respiratory equipment should be cleaned and bagged when not in use, but observations showed these items were left exposed in the resident's room, contrary to established procedures.
Nurses and nurse aides lacked the necessary competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards.
A resident with arthritis and edentulism experienced prolonged use of broken dentures due to the facility's failure to arrange timely dental services, despite requests from the resident's DPOA and documented care plan instructions. Staff were aware of the issue, but efforts to secure a dental appointment were insufficient, and no alternative solutions were pursued.
A consultant pharmacist did not recommend a gradual dose reduction for a resident's psychotropic medication, buspirone, as required by facility policy. The resident, who had multiple diagnoses including anxiety and dementia, continued to receive both buspirone and bupropion without documented review or physician rationale for ongoing use. Pharmacy reviews noted no irregularities, and the required consultation and documentation for GDR were not completed.
Staff did not follow physician-ordered parameters for holding blood pressure medication for a resident with hypertension, atrial fibrillation, and heart failure. Despite orders to hold metoprolol if systolic blood pressure was below 100 mmHg, the medication was repeatedly administered when readings were below this threshold, as documented in the MAR. Nursing staff acknowledged the parameters, but the medication was still given outside of those guidelines.
Staff did not label two residents' in-use insulin pens with required dates and failed to remove expired medications from a medication cart. A nurse and administrative staff confirmed that insulin pens and expired medications should have been properly labeled and disposed of according to facility policy.
A resident with arthritis and intact cognition reported missing and loose teeth in her dentures, and her DPOA requested a dental appointment. Despite care plan instructions and documented requests, staff did not arrange for dental evaluation or repair, and the social service designee only attempted to contact one local dentist without further follow-up or exploring additional options.
A resident with severe cognitive impairment and dementia was not dressed according to her care plan preferences, leading to an exposure incident in the dining room. The staff failed to ensure the resident wore a bra, as specified in her care plan, compromising her dignity. Observations and interviews confirmed the oversight, highlighting a lapse in adhering to the facility's policy on resident rights.
Failure to Provide Ordered Restorative Therapy
Penalty
Summary
The facility failed to provide restorative therapy services to multiple residents with documented restorative care plans and mobility or functional limitations. Resident 3 had diagnoses including muscle weakness, difficulty walking, unsteadiness on feet, and gait abnormalities, and his care plan directed active range of motion with orange bands and use of the NuStep several times weekly. Resident 4 had diagnoses of CVA, aphasia, right-sided hemiparesis/hemiplegia, and Parkinson’s disease, with a care plan directing active range of motion with orange bands. Resident 5 had dementia, psychotic disturbance, mood disturbance, and anxiety, and his care plan directed range of motion to all extremities with green bands and use of the NuStep. Resident 6 had dementia, psychotic disturbance, mood disturbance, and anxiety, and her EMR documented restorative therapy was to occur 4-6 times weekly. Resident 7 had Parkinson’s disease, anxiety, and hypertension, and her care plan directed restorative therapy 4-6 times daily. Record review showed the restorative therapy documented in the EMRs did not match the care plan expectations for these residents. Resident 3 had received restorative therapy on only two days in the last 30 days, Resident 4 on eight days in 30 days, Resident 5 on four days in 30 days, Resident 6 on nine days in 30 days despite a care plan lacking restorative interventions, and Resident 7 on five days in 30 days. The quarterly MDS assessments also reflected limited restorative therapy during the seven-day look-back period for Residents 3, 4, 5, and 7, while Resident 6 had zero days of restorative therapy. No opportunities for observations of restorative therapy existed over two consecutive days. Staff interviews identified that CNAs were responsible for completing restorative therapy, but multiple staff stated there was not enough staff or time to complete the restorative tasks. An administrative nurse stated CNAs on each floor were responsible for restorative therapy and evening shift would complete tasks not done on day shift. A CNA stated there was not enough staff and not enough time in an eight-hour shift, another CNA stated staffing was insufficient on heavier care halls, and two LNs stated there were not enough staff to get restorative done and that they could not ensure CNAs completed tasks all the time. The facility’s restorative nursing policy stated maintenance and restorative services were to be provided to maintain or improve residents’ abilities to the highest practicable level and that all residents would receive maintenance services as needed by CNAs.
Insufficient Staffing Led to Missed Restorative Nursing Services
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure residents on restorative programs received the restorative services ordered in their care plans. Resident 3 was to receive active range of motion to all extremities using orange bands 15-20 reps 4-6 times weekly and use the NuStep 10-15 minutes a day 4-6 times a week, but the EMR showed only two days of restorative therapy in the last 30 days. Resident 4 was to receive active range of motion to all extremities using orange bands 10-15 reps 4-6 times weekly, but the EMR showed only 8 days of restorative therapy in 30 days. Resident 5 was to receive range of motion to both upper and lower extremities with a green band and NuStep sessions 4-6 times weekly, but the EMR showed restorative therapy only four times in 30 days. Resident 6 was to receive restorative therapy 4-6 times weekly, but the EMR showed participation only nine times in 30 days. Resident 7 was to receive restorative therapy 4-6 times daily, but the EMR showed only five days of restorative therapy in 30 days. Staff interviews confirmed the staffing problem: an Administrative Nurse stated CNAs on each floor were responsible for restorative therapy and that evening shift would complete tasks not done on day shift; CNAs stated there was not enough staff or time to complete restorative therapy; and LNs stated there were not enough staff to get restorative done, they could not ensure CNAs completed all tasks while covering multiple floors, and there was no accountability when the nurse was off the floor. The facility policy stated all residents would receive maintenance services as needed by CNAs.
Failure to Complete Accurate Pre-Hire Background Check
Penalty
Summary
The facility failed to implement its policy to conduct a criminal background check before hiring one dietary employee. Dietary Staff BB’s personnel file showed a hire date of 02/24/26, but the file did not contain evidence that an accurate background check had been completed before employment began. The file later showed that the facility became aware of a concern regarding Dietary Staff BB and completed another background check using the correct name on 06/29/2026, which revealed convictions for crimes against a person. Dietary Staff BB was then terminated from employment. On 07/07/2026 at 10:00 AM, Administrative Staff A stated that the human resources employee at the time had spelled Dietary Staff BB’s name incorrectly on the original background check, and that the check had come back clear because of the error. The facility’s undated Employee Background Check Policy stated that it was committed to protecting residents from abuse, neglect, and exploitation and required pre-hire background checks to verify that individuals had not been found guilty of abuse, neglect, exploitation, mistreatment, or misappropriation of property by a court of law, did not have a finding in the state nurse aide registry for those offenses, and did not have disciplinary action in effect against a professional license.
Failure to Ensure CNA Competency in Resident Care and Dignity
Penalty
Summary
The facility failed to ensure CNAs had sufficient training and competencies to provide care in accordance with standards of practice for two residents. One resident had muscular dystrophy, a prior cerebral infarction with residual deficits, dizziness, osteoarthritis, intact cognition, and was dependent on staff for most ADLs. Her care plan and assessments documented decreased ability to care for herself and risk for further ADL decline, falls, skin breakdown, and pain. During an evening transfer and bedtime care, CNA M brought a full lift into the resident’s room, removed the scooter handlebars, placed the sling behind her, and then left the resident in the room while going to assist another resident and later to find another CNA. The resident stated she was left without her call light and without a way to move her electric chair to reach help, and that she had to yell for about thirty minutes while feeling too hot and dizzy. CNA M stated she left the room for about fifteen minutes and acknowledged she should have used her walkie-talkie instead of leaving the resident alone. A second resident had dementia, psychotic disturbance, mood disturbance, and anxiety, with moderate cognitive impairment, memory deficits, and a care plan requiring assistance with ADLs and management of an indwelling urinary catheter. The care plan directed staff to anchor the tubing, provide catheter care, check for kinks, and monitor intake and output. During observation, the resident was seated in a wheelchair in the dining room with the catheter bag attached to the wheelchair and no privacy cover over the urine bag. When CNA N and CNA O were made aware that the catheter bag lacked a privacy cover, they did nothing and walked away to perform other duties. Both CNAs stated they were not aware anything was wrong, then acknowledged the catheter should have been covered to maintain dignity. At the time of the review, Administrative Nurse E stated she could not provide CNA M’s and four other randomly selected CNAs’ competencies because of a filing error and no one knew where the competencies were. Administrative Nurse D stated the catheter should have been covered with a privacy leaf and that it was staff’s job to maintain the resident’s dignity. The facility’s Nursing Services and Sufficient Staff policy stated it was the facility’s policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individual plans of care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not provide sufficient oversight to mitigate these risks. The report specifically notes the lack of appropriate measures to prevent accidents, but does not provide further details about individual residents, their medical history, or their condition at the time of the deficiency.
Lack of Certified Dietary Manager in Food Service Supervision
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager (CDM) to supervise meal preparation and kitchen sanitation for its 84 residents. Observations showed that a dietary staff member, who was not certified as a dietary manager but was currently enrolled in a certification course, was managing the kitchen and overseeing meal production. The Registered Dietitian communicated with the dietary staff member weekly, reviewed resident charts remotely, and visited the facility weekly. Administrative staff confirmed that the acting Dietary Manager was not certified at the time of the survey. The facility's policy indicated that the Dining Services Manager was responsible for directing all food service activities to ensure safe food and a positive dining experience for residents.
Failure to Maintain Cleanliness in Kitchen Food Storage Drawers
Penalty
Summary
Surveyors observed that three drawers in the facility's main kitchen contained food crumbs and dried liquid spills among scoops and ladles. This was confirmed by a dietary staff member, who acknowledged that the drawers had dried food spills and required cleaning. Review of the facility's Sanitation of Dining and Food Service Area policy indicated that a cleaning schedule should be posted and staff are responsible for completing and initialing cleaning tasks. The failure to maintain cleanliness in the kitchen drawers was identified during a review of food storage and preparation practices for a facility with a census of 84 residents, including a sample of 27 residents. No information was provided regarding the medical history or condition of specific residents at the time of the deficiency.
Widespread QAA Program Failures and Multiple Care Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) program failed to identify and address multiple care issues affecting all 84 residents, as evidenced by observations, record reviews, and interviews. Specific deficiencies included a resident not receiving dignified dining service, lack of gradual dose reduction for a resident on psychotropic medication, failure to provide bed hold policy and ombudsman notification for two residents, and failure to revise care plans for residents with supplemental oxygen and an immobilizer brace. Additional issues included failure to prevent and manage skin breakdown, provide foot care, follow transfer protocols resulting in a knee fracture, and implement nutritional interventions for a resident with significant weight loss. There were also failures in communication regarding wound care, provision of annual in-service training for CNAs, and follow-up on a resident's request for new dentures. Further deficiencies were noted in pharmacy oversight, medication management, dental services, dietary management, kitchen sanitation, and infection control practices, including improper use of PPE and handling of soiled linens. The facility also lacked a Certified Dietary Manager and failed to maintain a sanitary kitchen environment. The QAA committee reportedly met monthly, but the ongoing issues indicated a lack of effective identification and resolution of care concerns, placing all residents at risk for unidentified and ongoing care issues.
Failure to Ensure Required In-Service Training Hours for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training per year, as evidenced by employment records showing that two nurse aides had not completed the mandated training hours. Specifically, one aide had completed only 6.5 hours and another 7.5 hours of the required 12 hours within the past year. This deficiency was identified through record review and staff interviews, which confirmed the shortfall in training hours. Administrative staff reported that the facility had recently changed ownership, and the previous owner managed human resources and training records offsite. As a result, the current administration had to rely on the previous company to provide information regarding in-service hours, and the records received indicated the deficiency. The facility's policy required all staff, including full-time, part-time, and PRN, to complete mandatory training within specified timelines, with managers responsible for tracking and addressing non-compliance.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures in multiple instances, as observed by surveyors. Laundry staff were seen handling soiled resident clothing while wearing only gloves, without the use of gowns or aprons as barriers, contrary to the facility's policy that requires standard precautions and the use of barriers to prevent contamination of uniforms. The staff member stated that gowns or aprons were only used for heavily soiled laundry, which does not align with the written policy. For one resident with chronic vascular ulcers and impaired cognition, staff did not follow Enhanced Barrier Precautions (EBP) during high-contact care activities such as toileting, transferring, and wound care. Despite clear care plan directives and physician orders to use gowns and gloves for all high-contact care and wound dressing changes, staff were repeatedly observed performing these tasks without the required personal protective equipment. Staff also demonstrated a lack of awareness regarding the EBP signage and its application to the resident in question. Another resident with a surgical wound and skin breakdown under a leg immobilizer did not have consistent EBP implemented. Staff were unaware of the skin breakdown, and there was a lack of clear care plan direction for monitoring and dressing changes. Observations revealed that staff did not always use gowns and gloves during wound care, and EBP signage was missing from the resident's room. Additionally, there was confusion among staff regarding the need for EBP for non-chronic wounds, and inconsistent documentation and assessment of the resident's skin condition.
Failure to Serve Meal Timely to Resident Requiring Assistance
Penalty
Summary
Facility staff failed to treat a resident who required assistance with eating in a dignified manner. On multiple occasions, the resident was seated at a dining table with two other residents who were served their meals and began eating while the resident waited, able to observe them eating but not being served herself. The resident remained unserved for extended periods, with breakfast and lunch being delayed until after the other residents had finished their meals. Staff only retrieved and assisted the resident with her meal after the others were done eating. Interviews with facility staff revealed that assistance for the resident was delayed due to competing priorities, such as responding to other residents' needs. Dietary staff waited for aides to be available before serving and assisting the resident, resulting in the resident not being served at the same time as her tablemates. The facility's policy required residents to be treated with respect and dignity, and to have their individuality recognized, but this was not followed in the observed incidents.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use without a gradual dose reduction (GDR) as required. The resident, who had diagnoses including anxiety disorder, hypertension, hallucinations, dementia, chronic pain, and depression, was prescribed buspirone for anxiety and depression. Despite the care plan directing staff to consult with the pharmacy and physician regarding dosage reduction at least quarterly, and to discuss the ongoing need for the medication, there was no evidence that a GDR was attempted or that the physician provided a documented risk versus benefit rationale for the continued use of buspirone. The consultant pharmacist's medication reviews over several months did not identify any irregularities or recommend a GDR, and the physician's orders continued the medication without documented justification. Observations showed the resident receiving and taking the prescribed medications without issue, and staff interviews confirmed that no GDR had been recommended or rationale documented for ongoing use. The facility's own policy required that residents on psychotropic medications receive GDR and behavioral interventions unless clinically contraindicated, with GDR attempts to be made within the first year of prescription and in at least two separate quarters. These requirements were not met for this resident, resulting in a deficiency related to the administration of unnecessary psychotropic medication.
Failure to Provide Bed-Hold and Ombudsman Notifications During Resident Transfers
Penalty
Summary
The facility failed to provide required bed-hold notifications to two residents and their representatives during hospital transfers, as well as ombudsman notifications for one resident. For one resident with diagnoses including extended spectrum beta lactamase infection, CHF, chronic kidney disease, and major depressive disorder, the electronic health record did not contain documentation of a bed-hold notification when the resident was transferred to the hospital for evaluation and treatment of respiratory and urinary symptoms. The administrative nurse confirmed that there was no evidence of a signed or verbally acknowledged bed-hold policy notice provided to the resident or their representative at the time of transfer. Another resident, who had a history of hemiplegia, hemiparesis, stroke, pain, and respiratory failure, experienced multiple discharges and returns to the facility. The progress notes indicated that the resident's durable power of attorney requested a bed-hold, but the facility did not provide a written bed-hold signature from the representative. Additionally, the facility was unable to provide an ombudsman notification policy for discharges and transfers, and social services staff confirmed that neither bed-hold notifications nor ombudsman notifications were sent for the resident's discharges. The facility's own policy, dated January 2024, requires that written notice specifying the duration of the bed-hold be provided to residents or their representatives at the time of transfer for hospitalization or therapeutic leave. Despite this policy, documentation and staff interviews revealed that these notifications were not provided as required, resulting in a deficiency related to resident rights and required notifications during transfers.
Failure to Update Care Plans for Oxygen Therapy and Leg Immobilizer Use
Penalty
Summary
The facility failed to revise and update the care plans for two residents to reflect significant changes in their care needs, specifically regarding the use of oxygen therapy and a leg immobilizer. For one resident with a history of hypertension, muscle weakness, atrial fibrillation, and bone disorders, the care plan did not include specific instructions for the use and monitoring of a leg immobilizer, nor did it address the presence of skin breakdown caused by the device. Despite physician orders specifying when the immobilizer should be removed and documentation of open sores on the resident's leg, the care plan lacked guidance for staff on daily skin monitoring and wound care. Staff interviews revealed a lack of awareness about the resident's skin condition, inconsistent dressing changes, and improper use of protective barriers between the immobilizer and the skin. Another resident, diagnosed with hemiplegia, hemiparesis, chronic respiratory failure with hypoxia, and other conditions, had a care plan that failed to include the use of prescribed oxygen therapy. Although the resident was receiving oxygen via nasal cannula and had physician orders for oxygen administration, the care plan only referenced the use of CPAP and nebulizer treatments. Observations confirmed the resident was using oxygen, and staff acknowledged that the care plan should have included this intervention. Additionally, equipment such as oxygen tubing, nebulizer, and CPAP were not properly stored or cleaned when not in use. The facility's own policy required comprehensive, person-centered care plans to be developed and revised as residents' conditions changed. However, in both cases, the care plans were not updated to reflect current physician orders or the residents' actual care needs, resulting in a lack of clear direction for staff and placing the residents at risk for unmet care needs.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents with existing pressure ulcers did not consistently receive the necessary interventions to promote healing. Additionally, preventive strategies to protect residents at risk for developing pressure ulcers were not adequately carried out, as required by care standards.
Failure to Provide Routine Foot Care
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including hypertension, muscle weakness, atrial fibrillation, and bone disorders, was observed to have long toenails, with some curling over the tops of her toes. The resident required staff assistance for lower body dressing, bathing, transfers, mobility, and personal hygiene, as documented in her care plan and MDS. The care plan also directed staff to monitor for brittle nails and provide assistance with footwear. Despite these documented needs, the resident's toenails had not been trimmed for an extended period, as observed by a licensed nurse who noted the condition and acknowledged the lack of recent foot care. Interviews with staff revealed confusion regarding responsibility for the resident's nail care, with some believing it was the nurse's duty and others stating it was the responsibility of CNAs during showers. The facility's nail care policy required routine trimming and filing of nails on a regular schedule and as needed. However, the lack of clear assignment and follow-through resulted in the resident not receiving appropriate foot care, as evidenced by the condition of her toenails at the time of the survey.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Store Respiratory Equipment in Sanitary Conditions
Penalty
Summary
The facility failed to maintain sanitary storage of respiratory care equipment for a resident with significant respiratory and neurological conditions. The resident had diagnoses including hemiplegia, hemiparesis following a stroke, chronic respiratory failure with hypoxia, and required the use of oxygen therapy, a nebulizer, and a CPAP machine. Observations revealed that the resident's oxygen tubing and nasal cannula were left unwrapped and draped around the top of a portable oxygen canister, while nebulizer and CPAP equipment not in use were left unwrapped or unbagged on bedside tables. Interviews with nursing staff and administrative personnel confirmed that these items should have been cleaned and stored in bags when not in use, in accordance with facility policy. Review of the facility's policies showed clear instructions that oxygen delivery devices, nebulizer mouthpieces, and CPAP equipment should be covered or stored in plastic or zip-lock bags when not in use. Despite these policies, the equipment was not stored as required, placing the resident at risk for respiratory infections. The deficiency was identified through observation, record review, and staff interviews, and was corroborated by documentation in the resident's medical record and care plan.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the appropriate competencies required to care for every resident in a manner that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked the necessary skills or knowledge to provide care tailored to the individual needs of residents. This failure resulted in residents not receiving care that supports their highest level of physical, mental, and psychosocial well-being, as required by regulatory standards.
Failure to Provide Timely Dental Services for Resident with Damaged Dentures
Penalty
Summary
The facility failed to provide adequate medically-related social services to address a resident's dental needs. The resident, who had a diagnosis of arthritis and was edentulous, was documented as having broken or loosely fitting dentures. The care plan instructed staff to assess the fit of the dentures, assist with oral care, and provide a dental evaluation if needed. Progress notes indicated that the resident's durable power of attorney (DPOA) requested a dental appointment after being informed of broken teeth in the dentures, and a message was sent to the social service designee (SSD). However, there was no documentation of follow-up or action taken by the SSD to secure a dental appointment or repair the dentures for nearly two months. During this period, the resident continued to use the damaged dentures, as observed during meal times, and staff interviews confirmed awareness of the issue. The SSD acknowledged being aware of the problem and stated that attempts to secure a local dentist were unsuccessful, but no further efforts were made to find alternative providers or consult with the DPOA about other options. The administrative nurse mentioned a possible issue with the resident's bone structure but could not provide documentation to support this. The facility's own policy required the provision of medically related social services to maintain or improve residents' abilities, but this was not followed in the resident's case.
Failure to Recommend Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility's consultant pharmacist failed to recommend a gradual dose reduction (GDR) for a resident's psychotropic medication, specifically buspirone, despite facility policy requiring quarterly consideration of dosage reduction for such medications. The resident in question had diagnoses including anxiety disorder, hypertension, hallucinations, dementia, chronic pain, and depression, and was receiving both buspirone and bupropion for anxiety and depression. The resident's care plan included interventions for behaviors and side effects, and directed consultation with pharmacy and the physician regarding GDR when clinically appropriate. However, pharmacy reviews over several months documented no irregularities, and there was no evidence that a GDR was recommended or that the physician provided a risk versus benefit rationale for the continued use of buspirone. Observations showed the resident was able to take medications without difficulty and displayed calm behavior during interactions, though she was noted to be confused but able to answer most questions. Interviews confirmed that the pharmacist had not recommended a GDR and that the physician had not documented a rationale for ongoing use of the medication. The facility's policy required the pharmacist to report findings and make recommendations to the physician and DON, including assistance with GDR reviews, but this process was not followed for the resident's psychotropic medication regimen.
Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
Facility staff failed to follow physician-ordered parameters for administering blood pressure medication to a resident diagnosed with hypertension, atrial fibrillation, and diastolic congestive heart failure. The physician's order specified that metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 100 mmHg or if the pulse was less than 55 beats per minute. Despite these clear instructions, the Medication Administration Records (MAR) for May, June, and July documented multiple instances where the resident received metoprolol even when their SBP was below the ordered threshold. The resident's care plan directed staff to monitor blood pressure as per physician orders and to administer medications accordingly. Interviews with nursing staff confirmed awareness of the medication parameters, yet documentation showed repeated administration of metoprolol outside of those parameters. Facility policy required documentation of medication administration and reasons for withholding medications, but the records indicated that the medication was given despite the resident's blood pressure being below the specified limit on numerous occasions.
Failure to Properly Store, Label, and Dispose of Medications and Biologicals
Penalty
Summary
Staff failed to properly store and label medications and biologicals as required by facility policy and professional standards. During a tour of the medication room, it was observed that two residents' in-use long-acting insulin pens were stored without labels indicating when the pens were put into use and their expiration dates. A licensed nurse confirmed that the insulin pens should have been labeled with these dates. The facility's insulin pen policy requires clear labeling with the resident's name, physician name, date dispensed, type of insulin, dosage, frequency, and expiration date, and specifies that pens should be disposed of after 28 days or per manufacturer recommendations. Additionally, expired medications were found on a medication cart, including a bottle of Prilosec with an expiration date of 05/2025 and a bottle of Maalox with an expiration date of 11/2024. A licensed nurse verified the expired status of these medications. The facility's medication storage policy requires that all medications be stored according to manufacturer recommendations and that medication rooms are routinely inspected for discontinued, outdated, defective, or deteriorated medications, which should be destroyed according to policy. Administrative staff confirmed that expired medications should have been removed and disposed of.
Failure to Provide Dental Services for Resident with Damaged Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident who reported missing and loose teeth in her dentures. The resident, who had a diagnosis of arthritis and was cognitively intact, was documented as being edentulous and wearing both upper and lower dentures. Her care plan instructed staff to assess the fit of her dentures and to provide a dental evaluation by a licensed dentist if needed. Progress notes indicated that the resident's durable power of attorney (DPOA) was informed about the broken dentures and requested a dental appointment, with no preference for a specific dentist. Despite these documented needs and requests, there was no evidence in the medical record that the social service designee (SSD) successfully arranged a dental appointment or followed up on the repair or replacement of the dentures over a two-month period. Observations showed the resident eating independently with her dentures in place, but staff interviews revealed a lack of awareness or action regarding the dental issue. The SSD acknowledged being aware of the problem but had only attempted to contact one local dentist who was not accepting new patients and had not explored other options or communicated further with the DPOA. The administrative nurse mentioned a possible issue with the resident's bone structure preventing new dentures but could not provide documentation to support this. The facility's policy required the provision of medically related social services to maintain or improve residents' abilities, but this was not followed in the resident's case.
Failure to Uphold Resident Dignity in Dressing
Penalty
Summary
The facility failed to honor a resident's right to dignity and personal preferences, resulting in a deficiency. A resident with severe cognitive impairment, dementia, and other behavioral symptoms required extensive staff assistance for activities of daily living, including dressing and personal hygiene. The resident's care plan specified a preference for wearing a bra, which was not adhered to by the staff. This oversight led to an incident where the resident exposed her bare breast in the dining room, compromising her dignity. Observations and interviews revealed that the staff did not follow the resident's care plan, which clearly directed them to ensure the resident wore a bra. A Certified Nurse's Aide acknowledged the responsibility to protect the resident's dignity and admitted that the resident should have been dressed according to her preferences. The resident's responsible party also expressed an expectation for the facility to meet the resident's needs and maintain her dignity. The facility's policy on resident rights emphasized the importance of treating residents with respect and dignity, which was not upheld in this instance.
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 24 citations issued within 25 miles in the last 12 months — 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 Hays
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Hays | 1.9 mi | ★★★★★ | 1 | 0 |
| Good Samaritan - Ellis | 14.2 mi | ★★★★★ | 12 | 0 |
| Wheatland Nursing & Rehabilitation Center | 23.5 mi | ★★★★★ | 0 | 0 |
| Russell Regional Hospital Ltcu | 23.6 mi | ★★★★★ | 0 | 0 |
| Redbud Village | 23.9 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.