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 resident with dementia and multiple behavioral health diagnoses experienced escalating aggression, wandering, and self-harm statements. The facility did not adequately assess or document behavioral triggers, failed to update the care plan with individualized interventions, and often did not notify the provider or representative of significant behavioral changes. Staff interventions were frequently ineffective, and the resident's behaviors continued to escalate, resulting in harm and eventual hospital transfer.
A resident with dementia and mental health diagnoses exhibited escalating aggression, suicidal ideation, and behavioral disturbances, especially after medication changes. Despite repeated documentation of these behaviors in the EMR, there was no evidence that the provider was notified as required by facility policy, resulting in a lack of timely intervention until the resident required emergency transfer.
Several residents experienced verbal and mental abuse when a CNA made derogatory remarks about their hygiene, attempted to physically force a resident out of bed, and neglected basic care tasks. Other staff members witnessed these actions but did not promptly report them, despite being trained on abuse and neglect policies.
Staff failed to promptly report observed and suspected abuse, including aggressive and verbally abusive behavior by a CNA toward multiple residents. Several staff members witnessed or were informed of inappropriate comments, harsh treatment, and attempts to physically force a resident, but did not immediately notify administration as required by policy. The affected residents included individuals with limited alertness, some of whom showed signs of distress.
Nursing staff did not consistently use required Enhanced Barrier Precautions or perform proper hand hygiene during direct care of two residents, including wound care and catheter management. In both cases, staff failed to don gowns and, in one instance, placed a catheter drainage bag on the floor, contrary to facility infection control policies.
Residents repeatedly reported long call light response times, incomplete care, and negative staff attitudes, including staff turning off call lights without providing assistance and being loud during activities. Despite ongoing complaints documented in Resident Council meetings and staff being re-educated, the same issues persisted, with residents continuing to feel neglected and disrespected.
The facility did not provide fully completed Medicare Advanced Beneficiary Notice (ABN) forms to three residents when skilled services ended, omitting the required estimated cost of services. This left residents without full information about their potential financial liability for non-covered services, as confirmed by administrative staff and facility policy.
A consultant pharmacist did not identify or report the lack of required blood pressure or pulse monitoring before administration of a beta blocker for a resident with multiple health conditions. Additionally, the facility did not implement the pharmacist's recommendation for specifying the dosage of Voltaren gel, resulting in incomplete medication orders. Staff interviews revealed uncertainty about monitoring requirements and the need for clear dosage instructions.
A resident with multiple complex conditions did not have blood pressure or pulse monitored prior to receiving a beta blocker, and physician orders for topical Voltaren gel lacked clear dosage instructions for some applications. Staff interviews confirmed uncertainty about monitoring requirements and acknowledged that medication orders should specify dosages, as required by facility policy.
A resident's injectable medications were found to be expired during a medication cart inspection. Both an LPN and an administrative nurse confirmed that the Lispro pens had been in use beyond their 30-day expiration period and should have been discarded, in accordance with facility policy.
Failure to Provide Individualized Dementia Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate dementia care and services to a resident diagnosed with vascular dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder. The resident exhibited ongoing and escalating behaviors, including aggression towards staff and other residents, wandering, and verbalizations of self-harm and suicidal ideation. Despite these behaviors, the facility did not adequately assess, identify, record, or respond to the resident's specific behavioral triggers, nor did they reassess and update the care plan with individualized interventions tailored to the resident's needs. The care plan lacked resident-specific strategies for managing behaviors and triggers, and staff interventions were often ineffective. Documentation in the resident's medical record revealed multiple instances where the resident displayed aggressive and unsafe behaviors, such as attempting to strike staff, refusing care, wandering, and making statements about wanting to die. Staff frequently attempted verbal redirection, which was documented as ineffective in many cases. There were also several occasions where the facility failed to notify the resident's provider or representative of significant behavioral changes, including suicidal statements and increased agitation following medication changes. The facility's own policy required individualized, person-centered care plans and prompt notification of changes in condition, but these were not consistently followed. Interviews with staff confirmed that the care plan did not include resident-specific interventions for dementia and that triggers for behaviors were not identified. Staff reported increased behavioral issues after medication changes, including aggression and sleep disturbances, but provider notifications were not always documented or made. The facility's deficient practice resulted in ongoing harm, as the resident's behaviors escalated without effective intervention, ultimately leading to the resident's transfer to the hospital for further evaluation and care.
Failure to Notify Provider of Resident's Escalating Behaviors and Suicidal Statements
Penalty
Summary
The facility failed to notify a resident's provider of new or escalating behaviors, as required by policy. The resident in question had a history of vascular dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder, and was admitted to the facility before being transferred to the hospital. The resident exhibited significant behavioral symptoms, including aggression, wandering, restlessness, physical aggression towards staff and other residents, suicidal and death statements, and increased agitation, particularly following the discontinuation of certain medications. Despite these behaviors being documented in the electronic medical record (EMR), there was no evidence that the provider was notified of these incidents over multiple periods. The care plan for the resident lacked individualized interventions related to the resident's specific behaviors and triggers. Multiple behavior notes documented incidents such as aggression, attempts to strike or bite staff, suicidal ideation, and increased fall risk. These behaviors were observed and recorded by staff, but the medical record did not show that the provider was informed of these significant changes or incidents, including after medication changes that appeared to exacerbate the resident's symptoms. Interviews with nursing staff confirmed that provider notification was expected in such cases, but documentation of such notifications was absent during critical periods. The facility's policy required immediate notification of the resident, physician, and representative when there was a significant change in the resident's physical, mental, or psychosocial status. However, the provider was not notified of the resident's escalating behaviors, suicidal statements, or increased agitation and aggression, particularly after medication adjustments. This lack of timely communication with the provider persisted until the resident's condition deteriorated to the point of requiring emergency intervention and hospital transfer.
Failure to Protect Residents from Verbal and Mental Abuse by CNA
Penalty
Summary
Multiple residents were subjected to verbal and mental abuse by a Certified Nurse's Aide (CNA), who made derogatory and inappropriate comments about residents' hygiene and physical condition. Witness statements documented that the CNA made repeated negative remarks about a resident's smell and food intake, used sarcasm, and laughed at another staff member's discomfort. The CNA also sternly reprimanded another resident in a public setting, causing visible distress. Additionally, the CNA was observed ranting and cussing in front of residents and expressing frustration about work assignments. Further incidents included the CNA attempting to physically force a resident out of bed against their will, despite the resident's resistance and verbal refusal. The CNA was also described as rushing through care routines, neglecting basic hygiene tasks such as brushing hair, wiping hands or faces, and changing soiled clothing. Another resident was subjected to unprofessional and hurtful comments about their cleanliness. Staff members who witnessed these actions did not immediately report the incidents to administration, with some expressing uncertainty or reluctance to escalate the situation. Licensed and certified staff interviewed after the incidents acknowledged they were trained on abuse, neglect, and exploitation (ANE) policies but failed to recognize or report the abuse at the time. Some staff rationalized their inaction by believing the incidents were isolated or that the affected residents were not alert and oriented enough to understand the abuse. The facility's policy required immediate reporting and intervention for any suspected abuse, but this protocol was not followed during the events described.
Failure to Timely Report Suspected Abuse and Aggressive Staff Behavior
Penalty
Summary
The facility failed to report suspected and observed abuse of six residents by a Certified Nurse's Aide (CNA). Multiple staff members witnessed or were aware of aggressive, verbally abusive, and unprofessional behavior by the CNA toward residents, including making derogatory comments about a resident's hygiene, speaking harshly to residents, and attempting to physically force a resident out of bed against his will. Witness statements documented that the CNA made repeated negative remarks about a resident's smell, yelled at another resident, and was generally snappy and cold toward residents during care routines. Other staff, including a Certified Medication Aide (CMA), another CNA, and a Licensed Nurse (LN), observed or were informed of these incidents but did not immediately report them to administration as required by facility policy and their training on abuse, neglect, and exploitation (ANE). Some staff expressed uncertainty or minimized the incidents, with one stating she thought it was an isolated event and another not wanting to create conflict with a coworker. The lack of timely reporting delayed the facility's awareness and response to the suspected abuse. The residents involved included individuals who were not alert and oriented, and some were visibly upset or verbally expressed distress during or after the incidents. Staff statements and facility documentation confirmed that the required immediate reporting of suspected abuse to administration and authorities did not occur as mandated by policy, resulting in a deficiency related to the timely reporting of suspected abuse, neglect, or theft.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Nursing staff failed to follow required Enhanced Barrier Precautions (EBP) and hand hygiene protocols during direct care of residents under infection control interventions. In one instance, a licensed nurse prepared wound care supplies for a resident with a pressure ulcer and entered the resident's room without donning a gown as required by EBP status. The nurse also failed to perform hand hygiene before donning gloves, between glove changes, and after completing the wound dressing change. Supplies were placed directly on the resident's bedside table, and the nurse exited the room without washing or sanitizing hands. The nurse later acknowledged not realizing the omission of the gown or hand hygiene steps during the procedure. In another instance, a certified nurse aide entered a resident's room to empty a catheter drainage bag but did not don a gown as required by EBP. The aide placed the catheter drainage bag directly on the floor while obtaining a privacy bag, contrary to facility policy that requires keeping the drainage bag off the floor. Both administrative nurses confirmed that staff are expected to use gowns and gloves during such care and that the drainage bag should not be placed on the floor. Facility policies on infection prevention and indwelling urinary catheters specify the use of standard and transmission-based precautions, including proper hand hygiene and environmental practices.
Failure to Resolve Recurring Resident Council Concerns on Call Light Response and Staff Attitude
Penalty
Summary
The facility failed to resolve recurring issues reported by the Resident Council regarding call light response times and delivery of care. Over the course of nearly a year, Resident Council meeting minutes repeatedly documented concerns that staff were turning off call lights without completing requested care, not returning to assist residents, and displaying negative attitudes such as huffing, scoffing, and cussing when residents requested assistance. Residents also reported that staff were loud during activities like church and movies, and that staff frequently complained about being short-staffed or about coworkers in the presence of residents. These concerns were consistently raised in multiple council meetings, indicating a pattern of unresolved issues. Despite the facility's stated responses, such as providing staff re-education and discussing concerns at staff meetings, the same issues persisted in subsequent Resident Council meetings. Residents continued to report long wait times for call light responses and feeling like a burden to staff. Observations and interviews confirmed that these problems were ongoing, with residents expressing dissatisfaction with staff attitudes and the timeliness of care. The facility's policy required a designated staff member to respond to council concerns and for the Quality Assurance Committee to review council data, but the recurring nature of the complaints suggests these processes were not effective in resolving the deficiencies.
Failure to Provide Complete Medicare ABN Forms with Cost Estimates
Penalty
Summary
The facility failed to provide fully completed Advanced Beneficiary Notice (ABN) CMS Form 10055 to residents or their representatives when skilled services ended. Specifically, for three residents reviewed for Medicare Liability Notices, the ABN forms given did not include the required estimated cost of continued services. The ABN is intended to inform beneficiaries that Medicare may not pay for future skilled therapy services and to provide an estimate of the potential financial liability if Medicare denies coverage. Record review showed that the ABN forms for these residents, issued at the end of their skilled services, were missing the estimated costs section. Administrative staff confirmed that the cost should be presented to allow for the possibility of appeal. The facility's policy indicated that the standard appeals process serves to notify beneficiaries of possible non-coverage and potential financial responsibility, but the omission of estimated costs on the ABN forms meant residents were not fully informed as required.
Failure to Ensure Pharmacist Review and Implementation of Medication Monitoring and Dosage Recommendations
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the omission of required blood pressure or pulse monitoring prior to the administration of an antihypertensive beta blocker, Carvedilol, for a resident with multiple diagnoses including hypertension, aneurysm of the heart, traumatic brain injury, and transient ischemic attack. The resident had severely impaired cognition and required significant assistance with activities of daily living. The care plan directed staff to monitor for side effects of hypertensive medications and to obtain blood pressure readings as per protocol, but the physician's order for Carvedilol did not specify monitoring requirements, and the CP did not report this omission during monthly drug regimen reviews from April to November. Additionally, the facility did not implement the CP's recommendation regarding the dosage amount for Voltaren gel, a topical medication prescribed for pain. The physician's orders for Voltaren gel on multiple occasions lacked a specified dosage amount for application to the affected areas, particularly for the left shoulder. Although the CP made a recommendation for a dosage amount, the physician's response only addressed the lower extremity and did not specify a dosage for the upper extremity. This resulted in continued orders without clear dosage instructions for all prescribed sites. Interviews with staff revealed uncertainty regarding which antihypertensive medications required monitoring prior to administration, and acknowledgment that all topical medications, including Voltaren gel, require a specified dosage for administration. The facility was unable to provide a policy regarding pharmacy review when requested. These findings demonstrate failures in both the identification and reporting of medication regimen irregularities and the implementation of pharmacist recommendations.
Failure to Monitor Antihypertensive Administration and Specify Topical Medication Dosage
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation for a resident receiving antihypertensive and topical pain medications. Specifically, staff did not obtain blood pressure or pulse readings prior to administering the beta blocker Carvedilol, as required for safe use of this medication class. The physician's order for Carvedilol lacked explicit instructions to monitor these vital signs before administration. Interviews with staff revealed uncertainty regarding which antihypertensive medications required such monitoring, and it was acknowledged by nursing leadership that monitoring should have occurred. Additionally, the facility did not ensure that physician orders for Voltaren gel, a topical pain medication, included clear dosage amounts for application to affected areas. Several orders for Voltaren gel were found to be incomplete, either lacking a specified dosage or omitting the amount to be applied to certain areas, such as the left shoulder. The facility's policy required that all medication orders include the dose and adequate monitoring, but this was not consistently followed for the resident in question, who had multiple complex diagnoses and required significant assistance with activities of daily living.
Expired Injectable Medications Found on Medication Cart
Penalty
Summary
The facility failed to ensure that injectable medications for one resident were not expired. During an observation of the medication and treatment cart, two Lispro injectable pens with an open date were found for a resident, and it was verified by a licensed nurse that these pens had been put into use on that date and expired 30 days after opening. Both the licensed nurse and an administrative nurse confirmed that the pens should have been discarded after 30 days, as per the facility's policy. The facility's Storage of Medication policy states that discontinued, outdated, or deteriorated drugs must not be used and should be returned to the pharmacy or destroyed according to state regulations.
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