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 deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of proper safety measures and oversight increased the risk of accidents for residents.
Multiple areas of the facility, including the hallway outside the kitchen and the laundry area, were found with broken tiles, standing water, missing flooring, exposed pipes, unsanitizable surfaces, and exposed electrical components. Staff and maintenance personnel were often unaware of these issues until they were reported, and the process for reporting maintenance concerns was inconsistently followed, resulting in unsafe and unsanitary conditions.
Surveyors observed that food items such as beef patties, hash browns, fish, and chicken strips were left open to air, and cutting boards had visible black residue and deep grooves. Pans and bowls were not properly covered or inverted, and these unsanitary conditions persisted on follow-up inspection, indicating a failure to maintain sanitary food storage and preparation practices.
Surveyors found that the kitchen had unsanitary conditions, including handwashing sinks with brown stains and grime, and a broken, uncovered trash can located near the food preparation area. Dietary staff confirmed the issues and the facility lacked a policy for trash disposal and hand sanitation equipment.
Numerous handrails in a resident hallway were found to be loose and easily moved by hand during a facility tour. Maintenance and administrative staff were unaware of the issue, despite facility policies requiring a safe environment and prompt reporting of damaged equipment.
A resident with multiple chronic conditions was administered several medications together after breakfast, despite orders requiring some to be given before meals and others with or after food. Staff confirmed the medications were not given as prescribed, contributing to a medication error rate of 17%, exceeding the required threshold.
Multiple environmental hazards, including exposed drywall, damaged ceilings, dirty floors, cracked tiles, and live open electrical outlets, were observed in resident rooms and common areas. Staff interviews revealed a lack of awareness and inconsistent use of the maintenance reporting system, resulting in unaddressed hazards and failure to maintain a safe, clean, and homelike environment as required by facility policy.
A resident with multiple mental health diagnoses was prescribed PRN clonazepam for anxiety and sleeplessness without a required 14-day stop date or physician justification for continued use. Facility staff confirmed the absence of a stop date or rationale, and no policy was provided to support compliance with regulations regarding PRN psychotropic medications.
A resident with a history of stroke, hypertension, and chronic kidney disease continued to receive Xarelto, an anticoagulant flagged by the consultant pharmacist for increased bleeding risk in older adults. The pharmacist recommended considering a switch to Eliquis, but the facility did not obtain a physician response or follow up on this recommendation for over 42 days, and lacked a policy for such follow-up.
A resident with Parkinson's disease, CHF, and DM was transferred to the hospital, but the facility did not notify the Ombudsman as required by policy. The electronic medical record lacked documentation of this notification, and staff confirmed the omission.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Maintain Safe and Sanitary Environment in Key Facility Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in several key areas, including the hallway outside the kitchen and the laundry area. Observations revealed multiple broken tiles and standing water in the hallway leading from the kitchen to the outside, which was being tracked into the kitchen. Dietary staff confirmed that water entered the hallway during rain and had to be mopped up to prevent it from entering the kitchen, while the broken tiles prevented proper sanitation. Maintenance staff were unaware of the broken and missing tiles until notified, and acknowledged that the area could not be properly sanitized. Additional observations found missing linoleum flooring behind the nurse's desk, with staff reporting that maintenance concerns should be entered into a computerized notification system, though this was not always done consistently. In the laundry area, there were several unsanitary and unsafe conditions, including an exposed, uncapped sewage pipe between washers, an unsealed and flaking ceiling in the dryer room, and heavily scuffed and chipped paint on walls, door frames, and storage cabinets, exposing wood and making the surfaces unsanitizable. A wall-mounted thermostat was also found without a cover, exposing electrical components. Maintenance staff stated they were unaware of these issues until recently and reiterated that all concerns should be reported through the facility's computerized work order system, but acknowledged that this process was not always followed by staff.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
During an inspection of the facility's main kitchen, surveyors observed multiple instances of improper food storage and unsanitary food preparation conditions. Specifically, a bag of beef patties, a bag of hash browns, a bag of fish, and a bag of chicken strips were found left open to air, and cutting boards had a black substance around the edges and deep grooves. Additionally, pans and bowls were not inverted or covered. On a follow-up visit, a box of beef patties remained open in the freezer, and the cutting boards still exhibited the same unsanitary conditions. The facility's policy required all dietary personnel and others preparing food for residents to be routinely instructed and evaluated in sanitary food handling techniques, hand washing, and personal hygiene, but these standards were not met as evidenced by the observations.
Unsanitary Kitchen Conditions Due to Improper Trash Disposal and Handwashing Sink Maintenance
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically regarding the storage and preparation of food. During an initial kitchen tour, the handwashing sinks were found to have brown stains and grime buildup around both the inner and outer edges. Additionally, a foot-operated trash can had a broken lid, which was found lying on the floor behind the trash can in a pile of used coffee grounds. The open trash can was located adjacent to the food preparation area, next to the steam table and a rack of clean dishes. Dietary staff confirmed that the trash should be contained to ensure food sanitation and prevent contamination. On a follow-up tour, the same uncovered trash can was observed at the handwashing sink in the food preparation area, and staff verified that it was the same broken trash can from the previous day. The facility did not provide a policy addressing trash disposal and hand sanitation equipment in the kitchen. These observations were made while the facility had a census of 26 residents and one main kitchen. No specific residents were directly involved or affected at the time of the deficiency.
Loose Handrails in Resident Hallway
Penalty
Summary
The facility failed to provide safe and functional handrails in one of two hallways, as observed during a facility tour when numerous handrails in the north resident hallway were found to be loose and easily moved by hand. Maintenance staff interviewed at the time were unaware of the loose handrails, and administrative staff also stated they were not aware of any such issues in the facility. The facility's policies require staff to maintain a safe environment and to report and repair damaged equipment, but these procedures were not followed, resulting in the deficiency being identified during the survey. The facility had a census of 26 residents at the time of the observation. No specific residents or their medical histories were mentioned in relation to the deficiency.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 17% error rate during medication administration. Out of 26 medications observed, four were administered in error. Specifically, a resident with a history of GERD, chronic pain, diabetes, and gastrointestinal issues was prescribed multiple medications with specific administration instructions, such as taking certain medications before meals, on an empty stomach, or with food. During observation, a Certified Medication Aide administered several of these medications together after the resident's breakfast, contrary to the prescribed instructions that required some to be given before meals and others with or after food. The resident also refused one medication, and another was held due to blood pressure readings. Staff interviews confirmed that the medications were not administered according to the physician's orders, with both the medication aide and a licensed nurse acknowledging the error. The nurse further verified that the resident had ongoing issues with vomiting and weight loss, and that the medications were intended to prevent these symptoms when given as ordered. The facility's policy required medications to be administered per the physician's schedule, and the error was confirmed by administrative staff, who noted that certain medications, such as Carafate, should be given separately to avoid interference with absorption.
Failure to Maintain Safe and Homelike Environment Due to Unaddressed Environmental Hazards
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in both resident rooms and common areas, as evidenced by multiple observations of environmental hazards and lack of timely maintenance. Surveyors observed dark spots and missing molding with exposed and broken drywall in one resident's room, damaged ceiling areas with exposed sheet rock, and dirty, stained floors. Another resident's room had a large area of exposed drywall and missing paint, with a dirty and sticky floor. The north hallway and rooms had chipped, cracked, and bubbled floor tiles, with some areas exposing the concrete underneath. Additional observations included a significant ceiling and wall crack extending between two rooms, a broken wall tile in the dining room, and multiple open 220-volt electrical outlets in both the dining room and north resident hall, all of which were live with electricity and located close to the ground. Interviews with maintenance and administrative staff revealed a lack of awareness regarding several of these hazards, and a breakdown in the facility's process for reporting and addressing maintenance concerns. Staff were expected to use a computerized maintenance management system (TELS) to report issues, but this was not consistently followed, resulting in unaddressed hazards. Maintenance staff indicated delays in repairs due to waiting for quotes or materials, and some hazards had not been reported or tracked as required by facility policy. Facility policies required a safe, clean, and comfortable environment and prompt maintenance service, but these were not adhered to, leading to the observed deficiencies.
Failure to Ensure 14-Day Stop Date or Justification for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a 14-day stop date or a physician's justification for continuation was in place for an as-needed (PRN) psychotropic medication prescribed to a resident. The resident, who had diagnoses including schizophrenia, cerebral edema, and adjustment disorder with anxiety, had an order for PRN clonazepam for sleeplessness and anxiety without a specified stop date or documented rationale for use beyond 14 days. Review of the resident's electronic health record and medication administration records confirmed the absence of a stop date or physician justification for the ongoing PRN order, despite facility staff acknowledging that such medications should have a 14-day limit unless otherwise justified. Observations of the resident showed them in various settings within the facility, and interviews with nursing and administrative staff confirmed the lack of compliance with the 14-day stop date requirement for PRN psychotropic medications. The facility was unable to provide a policy regarding 14-day stop dates for psychotropic medications. This deficiency was identified through record review, staff interviews, and direct observation, and it placed the resident at risk of unnecessary psychotropic medication use and related adverse effects.
Failure to Follow Up on Pharmacist's Anticoagulant Recommendation
Penalty
Summary
The facility failed to acknowledge and/or act on the consultant pharmacist's recommendation regarding the use of an anticoagulant medication for a resident with a history of stroke, hypertension, chronic kidney disease, and moderate cognitive impairment. The pharmacist had identified that the resident was receiving Xarelto, which is listed in the 2019 Beers Criteria as having an increased risk of serious bleeding in adults over 75 years when used long-term. The pharmacist recommended considering discontinuation or replacement of Xarelto with Eliquis and sent this recommendation to the physician for follow-up. Despite this recommendation, there was no evidence in the clinical record that the facility obtained a response from the physician or followed up on the pharmacist's recommendation for over 42 days. The administrative nurse confirmed that the lack of follow-up was an oversight and the facility did not have a policy in place to address follow-up on consultant pharmacist recommendations. This inaction resulted in the resident continuing to receive the medication without documented physician review or response to the identified irregularity.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital, as required by facility policy. The resident in question had diagnoses of Parkinson's disease, congestive heart failure, and diabetes mellitus, and was transferred to the hospital as documented in the electronic medical record (EMR). However, the EMR did not contain any documentation that the Ombudsman was notified of this transfer. During an interview, the administrative nurse confirmed that the Ombudsman had not been notified. The facility was unable to provide evidence of such notification, despite a policy stating that the Ombudsman must be informed of all resident transfers or discharges.
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