Azria Health Olathe

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with three reviewed for abuse and neglect. Based on observation, interview, and record review, the facility failed to ensure residents remained free from sexual abuse when cognitively impaired Resident (R) 16, a resident with a history of inappropriate touching, touched R75's genital area against R75's wishes. On 07/18/25, R16 touched a lady in a sexual way, and the facility sent R16 to the hospital for inappropriate behavior. R16 returned to the facility on [DATE], but the facility did not implement interventions to address R16's inappropriate touching. On 08/28/25, R16 exhibited sexual behaviors towards staff, but the facility did not address these behaviors with new interventions. On 08/29/25, R16 touched cognitively impaired R75, a resident unable to consent, in her genital area. [...]

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with five medication carts and three medication rooms. Based on observation, record review, and interviews, the facility failed to ensure an accurate reconciliation of controlled drugs at the end of daily work shifts and maintain the staff count sheets for the controlled drugs. This placed residents at risk for misappropriation of medications and/or diversion of controlled substances.

Inspectors wroteThe facility identified a census of 107 residents, with one kitchen and two dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to storage, preparation, and meal service. This deficient practice placed the residents at risk of food-borne illnesses and food safety concerns. Findings Included: - On 09/08/25 at 07:05 AM, a walkthrough of the facility's kitchen was completed. An inspection of the main kitchen area revealed:The floor was heavily dirty with old food debris and trash in the food prep and stove area. A soiled towel was on the floor next to the stove top ovens. Dessert saucers and plates were stored upwards in the dishware storage rack. An inspection of the dry food storage area revealed dirty floors and a soiled Band-Aid in the center of the dry food storage room floor. [...]

Inspectors wroteThe facility had a census of 107 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care.

Inspectors wroteThe facility had a census of 107 residents. The sample included 26 residents, with four reviewed for accommodation of needs for assistive device. Based on observation, record review, and interview the facility failed to utilize foot pedals during wheelchair transports for Resident (R) 37, R43, R104, and R122. This placed the residents at risk for preventable accidents. Findings Included: - On 09/09/25 at 07:40 AM, R37 (a severely cognitively impaired resident on the secured unit) was wheeled from her room to the dining room table. R37's wheelchair lacked foot pedals, and her feet slid on the ground as she was pushed. On 09/09/25 at 07:50 AM, R43 (a severely cognitively impaired resident on the secured unit) was wheeled to the dining room area from her room. Her wheelchair lacked foot pedals, and her feet slid on the floor as she was pushed. [...]

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents. The facility had one oxygen storage room on the 100 hall and one oxygen storage room on the 200 hall. The facility had a total of six cognitively impaired, independently mobile residents who resided on either the 100 or the 200 hall. Based on observation, record review, and interview, the facility failed to ensure oxygen tanks were stored in a securely locked room. The facility failed to ensure that Resident (R) 28's nothing by mouth (NPO) physician's order was followed. This deficient practice placed residents at risk of possible avoidable injury.

Inspectors wroteThe facility identified a census of 107 residents. The facility had three medication rooms and five medication carts. Based on observation, record review, and interview, the facility failed to ensure the medication cart was kept locked and secured with cognitively impaired and independently mobile residents on the hall. This placed the residents at risk of accidental ingestion of medication and adverse reactions.

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with five reviewed for dignity. Based on observation, record review, and interviews, the facility failed to provide a dignified care environment for Residents (R) 43 and R20. This deficient practice placed both residents at risk for impaired dignity and unmet care needs. Findings Included:- The Medical Diagnosis section within R43's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R43's Annual Minimum Data Set (MDS) completed 07/01/25 indicated a Brief interview for Mental Status (BIMS) score of zero (severe cognitive impairment). The MDS noted no upper or lower extremity impairments. [...]

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with two sampled residents reviewed for hospitalization and one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 1 and their representative were provided, as soon as practicable, a written notification of transfer upon their transfer to the hospital. The facility failed to ensure a discharge summary, and a recapitulation of R120's stay was completed upon discharge from the facility. This placed R1 and R120 at risk of miscommunication between the facility and the resident's representative, and the possible missed opportunity for healthcare services.

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with 26 residents reviewed for baseline care plans. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan for Resident (R) 121 to include her chronic pain. This deficient practice placed R121 at risk of impaired care related to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with four residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 14's low air loss mattress was at the correct weight setting, and R48's offloading boots were applied to her heels to prevent pressure ulcers. This placed R14 and R48 at increased risk for developing pressure ulcers. [...]

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents with one resident was reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 44 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R44 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension).

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 24's dialysis (a procedure where impurities or wastes were removed from the blood) physician order was in his orders of the Electronic Medical Record (EMR). The facility failed to ensure R24's care plan provided interventions to direct staff and implement care and services according to the professional standards of practice in order to meet the resident's dialysis care needs. This deficient practice placed R24 at risk for missed dialysis visits and complications related to dialysis.

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with three residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to assess and identify trauma-based triggers related to R11's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The facility failed to implement individualized interventions to prevent re-traumatization to R11. These deficient practices placed R11 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with two reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion). Based on interviews, record reviews, and observations, the facility failed to provide consistent dementia-related behavioral interventions for Resident (R) 16 to promote the resident's highest practicable level of well-being. This deficient practice placed R16 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included:- The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. [...]

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 25's insulin (a hormone that lowers the level of glucose in the blood) was given before meals according to the physician-ordered parameters related to blood glucose monitoring. This deficient practice placed R25 at risk for hypoglycemia (less than normal amount of sugar in the blood), delayed treatment, and unnecessary medication complications.

Inspectors wroteThe facility identified a census of 107 residents. The sample included 26 residents, with two residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Residents (R) 4 and R5. This placed the resident at risk for inadequate end-of-life care. [...]

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 residents with six residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to ensure a dignified care environment for Resident (R)33, R62, R75, R88, and R89. The facility additionally failed to provide dignity while dining when the facility used disposable silverware and dishware during meals. This deficient practice placed the residents at risk of unnecessary embarrassment and decreased psychosocial well-being. Findings Included: - The Facility Reported Incident 2181 documented that on 08/13/23, R33 assisted emergency medical services (EMS) by holding open a door so EMS could enter the facility. The report indicated Administrative Staff B approached R33 and told R33 to move out of the way. [...]

Inspectors wroteThe facility identified a census of 102 residents with six residents on puree textured diets. Based on observations, interviews, and record review, the facility failed to follow nutritionally approved recipes during the preparation of the facility's pureed meals. This deficient practice placed six residents at risk for complications related to nutritional impairment. Findings Included- - On 01/22/23 at 10:15 AM Dietary Staff BB placed a tin of cooked beef and another of beef stock in the preparation area. The food processor machine had previously been used for food and had not been washed before puree use. Dietary Staff BB placed the contents of the cooked beef in the food processor and started to puree the meat. Dietary Staff BB then added beef stock to the processor without measuring to amount of liquid stock to be added. [...]

Inspectors wroteThe facility identified a census of 102 residents with 22 residents included in the sample. The facility identified two residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 81 and R 28. This failure placed the residents at risk for impaired decision-making.

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 47's medical record. This placed this resident's personal and confidential information at risk of being accessed by unauthorized individuals.

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 residents with three reviewed for abuse and/or neglect. Based on record review, observations, and interviews, the facility failed to identify a preventable accident for Resident (R) 18, who was dependent on staff for transfers with a Hoyer (full body mechanical lift), as an allegation of potential neglect and failed to report to the State Agency (SA) as required within the required timeframe. This placed the resident at risk for unidentified and ongoing neglect.

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 residents. Based on record review and interview, the facility failed to provide written notification as soon as practicable to Resident (R) 58. This deficient practice had the risk of miscommunication between the facility and the resident.

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 residents with three residents reviewed for activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to provide the necessary assistance to Resident (R)62 for eating and drinking. These deficient practices placed R62 at risk of increased complications due to impaired ADL ability.

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 residents with one resident reviewed for hydration. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for fluid overload for Resident (R) 38. This deficient practice placed R38 at risk for delay in treatment related to fluid overload and untreated illness.

Inspectors wroteThe facility documented a census of 102 residents. The sample included 22 residents, with 10 reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure an environment free from preventable accidents when staff failed to correctly place the loop of the sling during a Hoyer lift (total body mechanical lift used to transfer residents) transfer which resulted in resident (R)18's fall to the floor from the lift. The facility further failed to ensure Dycem (non-slip mat used for stabilization and gripping to prevent slipping) was placed correctly in R75's wheelchair. These deficient practices placed R18 and R75 at risk for avoidable injuries.

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 residents with four reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, observations, and interviews, the facility failed to ensure Resident (R) 18's catheter bag (urine collection bag) was kept below his bladder during a Hoyer (full body mechanical lift) transfer. This deficient practice placed R18 at increased risk for infection and other catheter-associated complications.

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 with three reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to provide appropriate dementia care and services to address Resident (R)60's wandering behavior. This deficient practice placed R60 at risk for decreased quality of life due to the inability to maintain her highest practicable level of functioning.

Inspectors wroteThe facility identified a census of 102 residents with one kitchen and two dining areas. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food preparation, service, and storage. The facility additionally failed to ensure sanitary cleaning of kitchen service areas and equipment. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns. Finding Included: - On 01/17/24 at 08:03 AM an inspection of the facility's kitchen was completed. An inspection of the microwave oven revealed dried food residue on the top and back walls of the inside of the microwave. The kitchen's deep fryer contained dark brownish oil covered with old food debris all over the inside and outside the frying unit. [...]

Inspectors wroteThe facility identified a census of 102 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to ensure staff followed appropriate infection control practices and procedures when Resident (R)88's oxygen tubing and nasal cannula (a hollow tube used to deliver supplemental oxygen) were left on the floor. The facility further failed to ensure nursing staff appropriately sanitized a community-used Hoyer (total body mechanical lift) after each use. This deficient practice placed the residents at risk related to infectious diseases.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents; five residents were reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Eighteen residents resided on the memory care unit. Based on observations, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 248 when the facility failed to identify and implement resident-centered interventions to address violent/aggressive behaviors, wandering, and negative resident-to-resident altercations which included physical aggression. The facility further failed to assess, identify, record, and respond to R248's specific behaviors, triggers, and past/present interests and activities in order to promote an environment which supported R248's individualized care needs. [...]

Inspectors wroteThe facility identified a census of 99 residents. The facility had one main kitchen. Based on observation, record review, and interview, the facility failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened and the food item was not placed in a sealed container/storage bag with the proper labeling and date. The facility further failed to ensure prepared pitchers of drinks were labeled and dated. This deficient practice had the potential for food borne illnesses for residents.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to notify Resident (R) 31's Durable Power of Attorney (DPOA- legal document that names a person to make healthcare decisions when the resident was no longer able to) when R31 was transferred to the hospital for change in mental status. This deficient practice had the risk for miscommunication between R31, their DPOA, and the facility.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review, and interviews, the facility failed to provide form CMS 10123, Notice of Medicare Non-Coverage (NOMNC- a notice that indicated when the resident's care was set to end from skilled nursing facility [SNF]). It includes information for how to appeal the provider 's decision to a Quality Improvement Organization for Resident's (R) 66, R56, and R71. This deficient practice placed three residents at risk for uninformed decisions.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents; two residents reviewed for hospitalization. Based on observations, record reviews, and interviews, the facility failed to provide a written notification of transfers to Resident (R) 63 or to her family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) for documentation of anticoagulant (medication used to prevent blood from thickening or clotting) use for Resident (R) 2, R76, and R94. This deficient practice had the risk for miscommunication related to anticoagulation status.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to remove an discontinued or unnecessary intervention on R39's care plan. This deficient practice placed the resident at risk for ineffective or unnecessary treatments. Findings Included- -The electronic medical record (EMR) indicated the following diagnosis for R39: [...]

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents with five reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R) 298. This deficient practice placed the residents at risk for ineffective skin care and decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents, with five residents reviewed for activities. Based on observation, record review, and interviews, the facility failed to consistently provide activities for Resident (R)52. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents with five reviewed for incontinence care. Based on observation, record review, and interviews, the facility failed to implement incontinence care interventions for Residents (R) 28, R86 and R298. This deficient practice placed the residents at risk for complications related to incontinence. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R28: [...]

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to provide care and assistance, consistent with professional standards of practice, for Resident (R)13's prosthesis, related to his preference to wear his prosthetic device and his goal to return home. This deficient practice placed R13 at risk for impaired dignity and loss of independence.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents with one reviewed for pain. Based on observation, record review, and interviews, the facility failed to provide non-pharmacological pain interventions for Residents (R) 298. This deficient practice placed the residents at risk for ineffective pain management and decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents, with one resident reviewed for hemodialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to document arteriovenous (AV-a surgically created connection between artery and a vein used for hemodialysis) fistula for thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with stethoscope that may occasionally also be palpated as a thrill) every day for Resident (R) 71. This deficient practice placed R71 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents with five reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for Resident R36's hypertensive medication (class of medication used to treat hypertension [high blood pressure]) given outside the physician ordered parameters, and for irregularities related to bowel movement monitoring for R81. This deficient practice which had the potential of unnecessary medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility identified a census of 99 residents. The sample included 23 residents with five reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)36's hypertensive medication (class of medication used to treat hypertension [high blood pressure]) were administered as ordered by the physician, and failed to ensure bowel monitoring for R81. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects.