Citations in Kansas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Kansas.
Statistics for Kansas (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Kansas
Latest Citations in Kansas
A nurse performed wound care on a resident without wearing a gown as required by Enhanced Barrier Precautions and did not consistently perform hand hygiene between glove changes. The nurse also transitioned between wounds without completing care on one before starting another, contrary to facility policy. These actions were confirmed by staff interviews and review of facility infection control policies.
Two residents were placed at risk when a nurse signed out controlled medications on the count sheet without documenting administration in the EMAR, and falsified witness signatures for medication destruction. The nurse signed out medications for a resident who was not present and used another nurse's initials without permission, violating facility policy and resulting in missing medications and inaccurate records.
A CNA was found to be working without a current and valid certification, as confirmed by a review of personnel files and the Nurse Aide Registry. Administrative staff acknowledged the requirement for current certification, but the facility lacked a policy for CNA certificate renewal.
The facility did not complete required annual performance evaluations for two CNAs, as shown by missing documentation in their personnel files. Administrative staff confirmed that annual evaluations were expected, and facility policy supported this requirement.
Surveyors found that food items, including meat and bread, were not stored or dated properly in the kitchen. Open bags of meat were left unsealed, some food was stored on the floor, and several items lacked required date labeling. Moldy bread was also found past its expiration date, and food debris was present on the freezer floor.
A review of CNA training records found that some staff did not receive required in-service education, including dementia care, and lacked documentation of the mandated annual training hours. Facility policy required at least 12 hours of continuing education per year for nurse aides, but records and interviews confirmed this standard was not met.
Staff did not consistently follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols during tube feeding care, resident transfers, and peri-care. A nurse and certified nurse aides failed to use gowns and did not disinfect equipment or perform proper hand hygiene between tasks, placing residents at risk for infection.
The facility did not ensure that a CPR-certified staff member was present at all times for residents with Full Code status. A nurse held a CPR certificate without a hands-on component, and a CNA responsible for transporting a resident with Full Code status had an expired CPR card. The facility lacked a system to track and guarantee CPR-certified staff coverage on each shift, despite policy requirements.
Several residents were not invited to participate in their care plan meetings, and there was no documentation of such meetings in their records for the past six months. Staff interviews confirmed that care plan invitations had not been sent since the departure of the Clinical Reimbursement Coordinator, contrary to facility policy requiring resident and family involvement in care planning.
Surveyors observed multiple areas of disrepair and lack of cleanliness, including exposed concrete in a bathroom, missing vent covers, unmade beds stored in a resident's room, and missing tiles and baseboards throughout the facility. Staff interviews confirmed that these issues had persisted for weeks and that maintenance was unable to complete repairs due to shifting priorities and lack of clear direction. The facility did not provide a policy for maintaining a homelike environment.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a licensed nurse performed wound care on a resident without adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. During the wound care procedure, the nurse donned gloves but failed to wear a gown as required for EBP. The nurse also did not consistently perform hand hygiene between glove changes, specifically after removing gloves and before donning new ones during the care of multiple wounds. The nurse transitioned between treating the resident's leg wound and coccyx wound without completing care on one wound before moving to the next, contrary to facility expectations and infection control best practices. Interviews with nursing staff and administrative nurses confirmed that the facility's policy required the use of both gown and gloves for wound care under EBP, completion of care on one wound before addressing another, and hand hygiene with every glove change. The facility's infection control policy also documented that all team members would be trained on these practices. The observed failure to follow these protocols during wound care placed the resident at risk for wound infection and related complications.
Misappropriation and Falsification of Controlled Medication Records
Penalty
Summary
The facility failed to protect two residents from misappropriation of their controlled medications. During a random controlled substance audit, discrepancies were found in the documentation of medication administration for two residents. Specifically, several entries for controlled medications were signed out on the count sheet by a licensed nurse but were not documented on the Electronic Medication Administration Record (EMAR). Further review revealed that medications were signed out as being destroyed using another nurse's initials, as well as initials that did not belong to any licensed staff at the facility. The investigation found that on multiple occasions, controlled medications such as hydrocodone-acetaminophen, tramadol, and oxycodone were signed out and either not documented as administered or were documented as destroyed with falsified witness signatures. In one instance, a medication was signed out for a resident who was not present in the facility, having been admitted to the hospital at the time. Interviews with the nurse whose initials were used as a witness confirmed that she did not participate in the destruction of the medications and had not given permission for her initials to be used. Other licensed staff also denied witnessing or participating in the destruction of these medications. The nurse responsible for the discrepancies was unable to provide a consistent explanation for the documentation issues and admitted to signing another nurse's initials, claiming permission had been given, which was denied by the other nurse. The facility's policies required two licensed nurses to be present for the destruction of controlled substances and for accurate documentation of medication administration, which was not followed in these instances. The events led to the identification of missing medications and falsified records, placing the residents at risk for missed medications and further misappropriation.
Failure to Ensure CNA Maintained Current Certification
Penalty
Summary
The facility failed to ensure that one Certified Nurse Aide (CNA) maintained a current and valid certification. Review of personnel files showed that the CNA was hired in May 2022, but there was no evidence of a current CNA certificate in the file. Further review of the Nurse Aide Registry confirmed that the CNA's status had been inactive since June 2023. During an interview, administrative staff acknowledged the expectation that all CNAs should have current certification. The facility was unable to provide a policy regarding the renewal of CNA certification.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nurse Aides (CNAs) within the required 12-month period. Specifically, a review of personnel files showed that one CNA, hired in May 2022, and another CNA, hired in February 2020, did not have documentation of a performance evaluation conducted in the last 12 months. During an interview, administrative staff confirmed the expectation that all CNA staff should have annual performance evaluations completed. The facility's employee handbook also documented the importance of regular performance reviews as part of their performance management process.
Failure to Store and Date Food Items Properly in Kitchen
Penalty
Summary
Surveyors observed that food items in the facility's kitchen were not stored in a sanitary manner. Specifically, a bag of beef patties was found in the freezer with the plastic bag left open, and two bags of chicken in a store bag were placed on the floor of the refrigerator. The freezer floor had visible food debris, and numerous bags of vegetables and sandwich meat lacked a date received. Additionally, nine loaves of bread with an expiration date of 02/22/25 were found with mold growing on them. The Dietary Manager confirmed that staff were expected to date all food items with the open date, expiration date, and date received, and to rotate stock using the first-in, first-out method, but these procedures were not followed as observed.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training, including education on dementia care and abuse prevention, as mandated by facility policy and regulatory requirements. A review of training records for five CNAs revealed that at least two CNAs did not have documentation of dementia training, and one CNA's file lacked evidence of the total number of in-service hours completed. The facility's policy required all nurse aides to participate in at least 12 hours of continuing education annually, including dementia management. During an interview, administrative staff confirmed the expectation for staff to complete the required education and annual training hours.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
Staff failed to maintain effective infection control practices, specifically regarding Enhanced Barrier Precautions (EBP) and hand hygiene. During tube feeding care for a resident who had pulled out their feeding tube, a licensed nurse did not wear a gown as required by EBP protocols. In another instance, two certified nurse aides transferred a resident using a mechanical lift and provided a shower without donning gowns for EBP. After using the Hoyer lift, staff did not disinfect the equipment before moving it into the hallway. Additionally, a certified nurse aide provided peri-care to a resident and changed their brief while wearing the same soiled gloves, then handled the bedpan and continued care without performing hand hygiene between glove changes. The aide later acknowledged that handwashing should have occurred after glove removal and before continuing care. The facility's policy required appropriate precautions for residents with multidrug-resistant organisms (MDROs) and adherence to EBP, but these protocols were not consistently followed during observed care activities.
Failure to Ensure Presence of CPR-Certified Staff for Full Code Residents
Penalty
Summary
The facility failed to ensure that at least one staff member certified in cardiopulmonary resuscitation (CPR) was present at all times for residents who had chosen Full Code status. Review of staff records showed that one licensed nurse held a CPR certification from an online provider that did not include a hands-on skills component, contrary to facility policy. Additionally, the staff schedule did not identify which staff were CPR-certified for each shift, and there was no system in place to guarantee that a CPR-certified staff member was always present. A certified nurse aide responsible for transporting a resident with Full Code status to and from dialysis appointments did not have a current CPR certification, as her card had expired. Interviews with administrative staff confirmed that the facility did not track or ensure the presence of CPR-certified staff on each shift, and that some staff may not have completed the required hands-on component of CPR training. The facility's policy required staff to maintain current CPR certifications with a hands-on session and to have CPR-certified staff available 24 hours a day.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to participate in the development and implementation of their person-centered care plans. Multiple residents reported during interviews that they had never been invited to a care plan meeting and were unaware of what such meetings entailed. Review of the electronic health records for these residents confirmed the absence of documentation indicating that care plan meetings had been conducted in the past six months. Further investigation revealed that the staff member responsible for sending care plan meeting invitations had not done so since the departure of the Clinical Reimbursement Coordinator in October 2024. The Social Service Designee acknowledged that no invitations had been sent to residents or their responsible parties since that time. Facility policy requires that residents and their families be encouraged to participate in care planning, but this was not followed, as confirmed by both staff interviews and record review.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by multiple observations of disrepair and lack of cleanliness throughout the building. Surveyors noted several patches of white plaster on hallway walls and entrance doors, chipped floor tiles in resident hallways, and holes in the bathroom flooring of a resident's room exposing the concrete underneath. Additionally, a grab bar in the same bathroom was covered with frayed, worn duct tape. In another room, an air conditioning vent cover was missing from the ceiling and was found on a nightstand, and three beds were present, two of which were unmade and had a rolled-up air mattress on them. Staff interviews confirmed that the vent cover had been off for about a month and that the beds had recently been placed in the room for storage due to ongoing repairs elsewhere in the facility. Further observations revealed missing tiles and baseboards in the beauty shop and adjacent hallway, as well as partially painted bathroom floors and missing door trim in other rooms. Maintenance staff acknowledged awareness of these issues but reported difficulty completing repairs due to being redirected to other tasks and uncertainty about required materials. Housekeeping and medication aide staff confirmed the ongoing nature of these environmental concerns. The facility did not provide a policy regarding the maintenance of a homelike environment.
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