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)
Latest Citations in Kansas
A CNA did not have a required annual performance evaluation completed, as confirmed by facility administration and record review. The facility's policy mandates yearly evaluations to assess staff performance and training needs, but this process was not followed for the CNA in question.
The facility did not consistently identify or implement Enhanced Barrier Precautions for residents with PEG tubes and urinary catheters, failed to provide proper signage or PPE, and did not ensure sanitary storage of oxygen cannulas. Staff also did not always follow hand hygiene protocols or use barriers during blood glucose monitoring, resulting in multiple infection control deficiencies.
The facility did not maintain consistent infection control logs or track antibiotic use as required, with the responsible nurse confirming that monthly antibiotic tracking had not been completed for several months. Infection surveillance and documentation were incomplete, and there was no evidence of systematic education on antibiotic use and resistance, contrary to facility policy.
The facility did not have a qualified and certified Infection Preventionist on site, relying instead on a corporate nurse who was not present and an administrative nurse without specialized infection prevention training. The facility also could not provide a policy for the Infection Preventionist role when requested.
Staff did not consistently document dishwashing, refrigerator, and freezer temperatures, and failed to wear required hairnets and beard guards in food prep areas. An open gallon of milk was found stored at an unsafe temperature without ice, and a staff member handled juice glasses by touching the drinking surface, contrary to facility policy.
Surveyors found that food items in multiple kitchenettes and a pantry were not labeled or dated, and daily temperature logs for dishwashers were not maintained. Administrative staff confirmed that these practices did not align with facility policies requiring proper labeling, dating, and documentation for food safety and sanitation.
Staff did not date an opened insulin pen and failed to remove an expired bottle of stock medication from the medication cart. A nurse and administrative staff confirmed that medications should be dated and expired items discarded, in accordance with facility policy.
The facility did not ensure RN coverage for at least eight consecutive hours each day, as required, on multiple occasions. Staffing records and schedules confirmed repeated days without an RN present, and administrative staff acknowledged the ongoing difficulty in maintaining RN staffing levels.
The facility did not offer or document informed declinations or physician-documented contraindications for PCV20 and pneumococcal vaccinations for three residents. Records lacked evidence that the vaccine was offered or declined, and the responsible nurse confirmed that PCV20 had not been offered, despite facility policy requiring vaccinations per CDC guidelines.
Surveyors found multiple medication and treatment carts left unlocked and unsupervised, containing prescription drugs, insulin, and treatment supplies. In one case, a cart laptop was left open, displaying a resident's protected health information. Staff interviews revealed uncertainty about locking requirements, despite facility policy mandating that all medications be secured and PHI protected.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
The facility failed to complete the required annual performance evaluation for one of five reviewed Certified Nurse Aides (CNA), specifically for a CNA hired on 09/30/23. During the review of performance evaluation and in-service records, no yearly performance evaluation was provided for this CNA upon request. The administrator confirmed that the evaluation was not available, and the administrative nurse stated that such evaluations are used to assess performance and identify areas for improvement among direct care staff. The facility's staffing policy requires annual performance reviews for all employees to identify strengths and training needs, but this was not followed for the identified CNA.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement and maintain its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with certain medical devices. Several residents with percutaneous endoscopic gastrostomy (PEG) tubes and urinary catheters were not identified for EBP, and there was no signage or indicators in their rooms to alert staff and visitors of the required precautions. Additionally, personal protective equipment (PPE) was not readily available in these residents' rooms, and staff members were unaware of the need for EBP for residents with these devices. Observations revealed improper storage of oxygen nasal cannulas, with some found on the floor or wrapped around wheelchair handles, and not stored in a sanitary manner as per facility policy. Staff interviews confirmed a lack of awareness regarding proper storage procedures, and the facility's own policy required cannulas to be stored in plastic bags and replaced if contaminated. Furthermore, during blood glucose monitoring, a licensed nurse failed to place a barrier under the Accu-check monitor before setting it down in a resident's room and did not perform hand hygiene before donning gloves, contrary to facility policy and standard infection control practices. Staff interviews indicated gaps in knowledge and adherence to infection control protocols, including hand hygiene and the use of EBP for residents with urinary catheters and PEG tubes. Facility policies outlined the requirements for oxygen equipment management, EBP, and hand hygiene, but these were not consistently followed, leading to multiple deficiencies in infection prevention and control practices.
Failure to Implement Antibiotic Stewardship and Infection Control Tracking
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control efforts. Specifically, the facility was unable to provide infection control logs for several months, which should have included tracking and trending of infections, identification of possible outbreaks, and documentation of antibiotic administration. The infection control surveillance lacked consistent identification of infections and proper documentation. The administrative nurse responsible for antibiotic tracking admitted that monthly tracking of antibiotic use had not been completed since May 2025, and review of physician-ordered antibiotics for appropriate criteria was only done for self-education, not as part of a systematic program. The facility's policy required education on proper antibiotic use and resistance, but there was no evidence this was being consistently implemented.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to designate a staff member with the required qualifications and certification as the Infection Preventionist responsible for the Infection Prevention and Control Program. Although a corporate nurse was listed as the Infection Preventionist, this individual was not present at the facility and only provided advice as needed. The administrative nurse on site stated he was responsible for the program but had not completed specialized education related to infection prevention. Additionally, the facility was unable to provide a policy regarding the Infection Preventionist when requested by surveyors.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
Staff failed to properly test dishwashing sanitization chemicals and did not consistently document freezer and refrigerator temperatures, as evidenced by missing entries on several days in the temperature logs. Additionally, an open, undated gallon of milk was found stored without ice at a temperature of 46 degrees, which was subsequently discarded. Staff members were observed not wearing required hairnets and beard guards while working in food preparation areas, and one staff member handled juice glasses by touching the drinking surface. Interviews with dietary staff confirmed that hairnets and facial hair nets should always be worn in the kitchen food prep area, and that glasses should be handled by the base to avoid contaminating the drinking surface. Staff also acknowledged that dishwashing machine, refrigerator, and freezer temperatures should be recorded daily, and that dairy products should be kept on ice to prevent spoilage. The facility's policy requires food to be stored at appropriate temperatures and for regular temperature checks to be conducted.
Failure to Properly Label, Date, and Store Food Items and Maintain Dishwasher Temperature Logs
Penalty
Summary
Surveyors observed that the facility failed to store food according to professional food service safety standards in two kitchenettes and one pantry room. Multiple food items, including potato salad, chicken patties, pancakes, vegetable beef soup, cranberries, strawberry yogurt, shredded American cheese, sliced Swiss cheese, chicken tenders, and diced chicken, were found in refrigerators and were not labeled or dated. Additionally, the facility did not maintain daily temperature logs for dishwashers in the kitchenettes since moving into the new facility, as staff believed that the use of low temperature dishwasher detergent eliminated the need for temperature documentation. Administrative staff confirmed these findings and acknowledged that food items should be labeled and dated before refrigeration or freezing. The facility's own policies required all products to be labeled with the date received and for food to be rotated appropriately, as well as for dishwashing and food storage practices to meet sanitary standards. However, these procedures were not followed, resulting in the cited deficiencies.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Staff failed to properly label and store medications and biologicals as required by facility policy and professional standards. During an observation of the medication room refrigerator, an opened insulin glargine pen belonging to a resident was found without an open date or discard date. Additionally, a medication cart inspection revealed a bottle of Thera High Potency Vitamin Dietary Supplement that had expired, yet remained in use. The bottle had been dated when placed in the cart, but the expiration date had passed. Licensed nursing staff confirmed that insulin pens are to be dated when opened and expired medications are to be discarded. Administrative staff also verified that medications should be removed once expired and that insulin pens require both an open date and an expiration date. Facility policies on medication administration and pharmacy services require all drugs and biologicals to be labeled according to accepted professional principles, including expiration dates, and to be stored and administered safely.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required by regulation and the facility's own policy. Payroll Based Journal (PBJ) records and nursing schedules documented multiple days across several months when there was no RN present in the building for the required duration. Administrative staff confirmed these absences and attributed the issue to difficulty in recruiting RNs due to the facility's rural location. The deficiency affected all residents in the facility, which had a census of 32, and was identified through interviews and record reviews, including a sample of 12 residents.
Failure to Document and Offer Pneumococcal Vaccinations per Policy
Penalty
Summary
The facility failed to offer or obtain informed declinations or physician-documented contraindications for the Pneumococcal Conjugate Vaccine (PCV20) and pneumococcal vaccination for three residents. Specifically, clinical records for these residents lacked documentation that PCV20 was offered, that an informed declination was obtained, or that a physician-documented contraindication was present prior to the survey. One resident's record indicated they were not eligible for PCV20, but there was no documentation of the vaccine being offered, a declination, or a contraindication. The facility's immunization report showed previous administration of other pneumococcal vaccines, but not PCV20. The administrative nurse responsible for immunization tracking stated that the facility had not offered PCV20 and would need to consult CDC guidelines regarding eligibility. The facility's policy required offering pneumococcal vaccinations to all residents per CDC guidelines.
Failure to Secure Medication Carts and Protect PHI
Penalty
Summary
Surveyors observed that three out of six medication carts in the facility were left unlocked and unsupervised, contrary to facility policy and accepted professional standards. On one occasion, an unlocked medication cart and an unsecured treatment cart containing prescription medications, stock medications, insulin, and treatment supplies were found unattended in the Blue Hall. A Certified Medication Aide later secured the carts and confirmed that staff were expected to lock them when not directly supervising. In another instance, an unsecured treatment cart containing stock medications, treatment supplies, and insulin was found outside a resident's room in the Red Hall. The cart's laptop was open, displaying a resident's picture and protected health information in direct view. A Licensed Nurse present was unsure about the locking requirements for medication carts but acknowledged that PHI should not be left open on computers when not in use. The facility's policy, revised in January 2021, requires that all drugs and biological agents be stored in locked compartments or areas and that staff supervise medications and biologicals during administration or use. Administrative staff confirmed that staff receive annual training on medication storage and resident safety expectations. Despite these policies and training, the observed lapses in securing medication carts and protecting PHI led to the identified deficiency.
Some of the Latest Corrective Actions taken by Facilities in Kansas
- Provided education to the Director of Nursing and Executive Director on incident-reportable event management and record review to strengthen oversight of abuse reporting (K - F0610 - KS) (J - F0609 - KS)
- Implemented comprehensive staff education for nursing employees on reporting suspected abuse, neglect, and exploitation, including misappropriation before their next shift (K - F0610 - KS) (J - F0609 - KS)
- Implemented interdisciplinary-team education on incident and reporting event management for all department heads prior to working their next shift (K - F0610 - KS) (J - F0609 - KS)
- Established ongoing random knowledge checks of five staff members on abuse-reporting protocols five times weekly for four weeks, three times weekly for four weeks, then randomly thereafter (K - F0610 - KS) (J - F0609 - KS)
- Directed submission of audit and knowledge-check results to the QAPI Committee for continuous review and action on trends (K - F0610 - KS) (J - F0609 - KS)
- Initiated staff re-education on abuse prevention, reporting, and sexual consent with cognitively impaired residents to reinforce correct practices (K - F0600 - KS)
Failure to Protect Resident from Staff-to-Resident Abuse and Delay in Restricting Perpetrator Access
Penalty
Summary
A deficiency occurred when a licensed nurse engaged in staff-to-resident abuse involving a resident with severe cognitive impairment, traumatic brain injury, and a history of aggressive behaviors. The incident began when the resident exhibited escalating combative and aggressive behaviors, including grabbing the nurse's genitals and using obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse further reported using a restraint technique involving grabbing the resident around the neck, which he described as a 'scare tactic.' A certified nurse aide witnessed the abuse but failed to report the incident to administrative staff until the following day. During this time, the nurse continued to have unrestricted access to the resident and other residents on the locked memory care unit. The facility did not immediately remove the nurse from resident care or restrict his access to vulnerable residents following the incident, contrary to facility policy and expectations for immediate response to allegations of abuse. The resident involved had a documented history of severe cognitive impairment, behavioral disturbances, and required specific interventions for agitation and aggression. Despite these known risk factors and care plan instructions for de-escalation, the nurse's actions escalated the situation and resulted in physical and verbal abuse. The facility's failure to act promptly to protect the resident and others from further potential abuse constituted a significant deficiency.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if Abuse, Neglect, or Exploitation (ANE), including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and/or action, as well as any trends identified.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A cognitively impaired female resident with severe cognitive impairment, a history of wandering, and inability to consent to sexual relations was not protected from sexual abuse by another resident. The male resident involved was cognitively intact, had a history of inappropriate sexual behaviors, and was known to make sexually explicit comments, gestures, and attempts at contact. Despite being aware of his inappropriate behaviors and receiving counseling and medication for hypersexuality, he continued to pursue and interact with the cognitively impaired resident. Multiple documented incidents occurred prior to the abuse event, including the male resident making inappropriate gestures, blowing kisses, and inviting the female resident to his room. Staff and social services were aware of these behaviors and had taken steps such as moving the male resident to a different room and providing education about consent and legal implications. However, the female resident continued to access the male resident's room, and staff interventions were insufficient to prevent further contact between the two residents. The deficiency culminated when staff found both residents in the male resident's room, both unclothed from the waist down, with the male resident performing oral sex on the cognitively impaired female resident. Interviews with staff and the male resident confirmed the incident and the ongoing pattern of inappropriate sexual behavior. The facility's failure to adequately supervise and prevent contact between the residents resulted in the female resident being subjected to sexual abuse.
Removal Plan
- Staff immediately separated R1 and R2, and placed R2 under one-on-one supervision, pending assessment
- R1 was placed on continuous monitoring, and R2 was restricted from unsupervised access to rooms
- Administrative Staff A and Administrative Nurse D initiated an internal investigation per the abuse policy upon knowledge of the incident, and after R1 and R2 were separated
- Staff re-education on abuse prevention, reporting, and sexual consent with cognitively impaired residents training initiated and continued for all staff to be re-educated prior to working the next scheduled shift until all staff had been re-educated
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A cognitively impaired resident with diagnoses including subarachnoid hemorrhage, dementia, anxiety, and insomnia, and who was identified as high risk for wandering, exited the facility unsupervised. The resident, who used a wheelchair and wore a Wander Guard, was able to open a delayed-egress door that alarmed upon activation. Despite the alarm sounding, no staff responded immediately. The resident propelled herself across the driveway and into the city street, traveling approximately 200 feet before being noticed by staff. At the time of the incident, the nurse on duty heard the alarm and saw the resident exiting but did not immediately respond to the door. Instead, the nurse returned to the nurse's station and only later proceeded down the hall, at which point the resident was already outside in the street. The nurse called for assistance, and a CNA responded, retrieving the resident and bringing her back inside. The facility's video footage confirmed that the resident was outside unattended for approximately three minutes and that the nurse did not maintain continuous visual observation of the resident during the elopement. The resident's care plan documented her as an elopement risk and included interventions such as structured activities, reorientation strategies, and signage on facility doors. However, the care plan was not effectively implemented, as staff failed to respond promptly to the door alarm and did not prevent the resident from leaving the premises. The facility's policy required immediate response to alarms and supervision of residents at risk for elopement, but these procedures were not followed, resulting in the resident's unsupervised exit.
Removal Plan
- Immediate 1:1 supervision with behavior monitoring were initiated for R7.
- Nursing counseling was provided to LN H and her supervisor on the facility's Elopement and Wandering policy.
- Facility-wide education was implemented regarding the immediate retrieval of a resident during an exit attempt in conjunction with a review of the elopement policy.
- Plan of care meetings were held with R7's family.
- A Behavior Monitoring log was initiated to assess for exit-seeking behaviors, restlessness, or patterns warranting intervention.
- The facility pharmacy consultant performed a focused medication review related to the resident's increased exit seeking to find family, brief recall of direction, and intermittent agitation.
- Administration contacted their door lock company to assess and repair any issues identified.
- The Director of Nursing submitted a report to the Kansas State Board of Nursing regarding LN H's failure to communicate that she did not have eyes on R7 the entire time of the elopement.
Failure to Immediately Report Staff-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with a history of traumatic brain injury and behavioral issues exhibited escalating combative and aggressive behaviors. During an incident, the resident grabbed a licensed nurse's genitals and used obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse also reported using a restraint technique involving grabbing the resident around the neck to prevent further aggression. A certified nurse aide witnessed this staff-to-resident abuse. Despite witnessing the incident, the certified nurse aide did not immediately report the abuse to administrative staff as required by facility policy. Instead, the incident was reported the following day when the aide returned for her next shift. This delay in reporting meant that the facility administrator was not promptly informed of the abuse, which is a violation of the facility's abuse prevention policy that mandates immediate reporting of all alleged or suspected abuse. The failure to ensure immediate reporting of the abuse placed the resident in immediate jeopardy. The facility's own documentation and staff interviews confirmed that the incident was not reported in a timely manner, and that the required notification to administrative staff was delayed until the next day. This lapse in procedure directly contributed to the deficiency cited by surveyors.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.
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