Via Christi Village Hays Ks Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hays, Kansas.
- Location
- 2225 Canterbury Dr, Hays, Kansas 67601
- CMS Provider Number
- 175498
- Inspections on file
- 25
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Via Christi Village Hays Ks Llc during CMS and state inspections, most recent first.
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 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.
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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