Flint Hills Care and Rehabilitation Center

Inspectors wroteThe facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to administer scheduled pain medication and take action to manage severe pain for Resident (R)32. Additionally, the facility failed to re-order the scheduled pain medication and notify the provider when the pain medication was not available. As a result of the deficient practice, R32 experienced severe pain with ineffective pain relief for two days and had physical symptoms of abrupt withdrawal, including nausea and vomiting, related to the facility not administering the scheduled, physician ordered pain medication. This also placed R32 at risk for discomfort and further decline in her overall well-being.

Inspectors wroteThe facility reported a census of 44 residents; the sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop and implement a system to ensure the presence of at least one staff certified in cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) during transportation provided by the facility for residents who desired a Full Code status (full resuscitative measures). This deficient practice placed the residents at risk for decreased quality of care and inadequate resuscitative measures.

Inspectors wroteThe facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care for Resident (R) 7. Additionally, the facility failed to provide adequate incontinence care (the management and support provided to individuals who experience involuntary loss of urine) for R40 and R34 when staff failed to complete proper hand hygiene and cleansing of the peri-area. The facility failed to store respiratory equipment in a sanitary manner for R32 and R20. [...]

Inspectors wroteThe facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to identify an elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) as a potential neglect and report to the State Agency (SA) as required. This placed the resident at risk for neglect and impaired safety.

Inspectors wroteThe facility had a census of 44 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 32 This placed the resident at risk for impaired rights related to returning to the facility.

Inspectors wroteThe facility reported a census of 44 residents; 12 residents were sampled for review. Based on observation, interview, and record review the facility failed to ensure accurate Minimum Data Set (MDS) assessments for Residents (R) 18, R42, and R7 related to urinary continence and/or indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) and R7 for communication/sensory status. The deficient practice placed the affected residents at risk for impaired care due to unidentified care needs.

Inspectors wroteThe facility reported a census of 44 residents. The sample included 12 residents, with one reviewed for hearing aid use. Based on the interview and record review, the facility failed to ensure that dependent Resident (R) 7 received staff assistance in placing his hearing aids. This placed the resident at risk for social isolation, mental decline, and loss of independence.

Inspectors wroteThe facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)30, identified as a high risk for elopement (when a cognitively impaired resident leaves the facility or safe area without staff knowledge or supervision). This placed the resident at risk for injuries, accidents, and further elopements.

Inspectors wroteThe facility reported a census of 44 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interview, and record review, the facility failed to notify the physician for blood sugars outside of the physician-ordered parameters for Resident (R) R29. The deficient practice placed the affected resident at risk for complications related to hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar)

Inspectors wroteThe facility reported a census of 44 residents. Based on record review and interviews, the facility failed to submit accurate staffing information through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours.

Inspectors wroteThe facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to ensure staff-maintained food on the steam table at a temperature of at least 135 degrees.

Inspectors wroteThe facility reported a census of 45 residents with nine residents selected for review, which included four residents reviewed for abuse, neglect, and exploitation. Based on observation, interview and record review, the facility failed to ensure staff were competent in interactions with aggressive behaviors for one Resident (R)9, with dementia.

Inspectors wroteThe facility reported a census of 44 residents with nine residents selected for review, including three residents reviewed for skin conditions. Based on record review and interview, the facility failed to provide appropriate treatment services for one Resident (R)7's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) at a Stage 3 (full thickness pressure injury extending through the skin into the tissue below), present on admission to her coccyx (area at the base of the spine) when they failed to obtain physician ordered treatment until seven days after admission to the facility, failed to assess the wound until three days after admission to the facility, failed to ensure R7 had a dressing replaced timely when soiled or absent, and failed to provide a [...]

Inspectors wroteThe facility reported a census of 44 residents. Based on observation, record review, and interview, the facility failed to have sufficient nursing staff at all times to meet the residents bathing needs and adequate call light response time.

Inspectors wroteThe facility reported a census of 44 residents with nine residents selected for review, including three residents reviewed for bathing. Based on observation, interview, and record review, the facility failed to provide two of two non-dependent residents, Resident (R)2 and R8 adequate bathing.

Inspectors wroteThe facility reported a census of 44 residents with nine residents selected for review, including three reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide adequate bathing for one dependent resident, Resident (R)6.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, interview and record review, the facility failed to provide infection surveillance tracking by organism to prevent the spread of infections.

Inspectors wroteThe facility reported a census of 43 residents. Based on interview and record review, the facility failed to ensure four Residents (R) 25, 40, 36 and 146 acknowledged receipt of COVID-19 vaccination information to make informed declination decisions as required.

Inspectors wroteThe facility reported a census of 43 residents with 15 sampled for review. Based on observation, interview, and record review the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)8, regarding an indwelling urinary catheter.

Inspectors wroteThe facility reported a census of 43 residents with 15 selected for review. Based on observation, interview, and record review, the facility failed to ensure laboratory tests ordered by the physician were completed for two Residents (R)18 and R 34 and failed to ensure proper wheelchair positioning for one resident R2.

Inspectors wroteThe facility reported a census of 43 residents with 15 residents included in the sample, including three residents reviewed for accidents. Based on observations, interview and record review, the facility failed to safely transfer one dependent Resident (R)24, by failing to lock the brakes of her wheelchair before transferring her from her wheelchair to the toilet.

Inspectors wroteThe facility reported a census of 43 residents with 15 residents sampled, including one resident reviewed for urinary catheter (a catheter (hollow tube) is inserted into the bladder to drain or collect urine). Based on observation, interview and record review, the facility failed to anchor the catheter tubing to one Resident's (R)8.

Inspectors wroteThe facility reported a census of 43 residents with 15 residents sampled including five residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to timely change oxygen tubing for one Resident (R)33.

Inspectors wroteThe facility reported a census of 43 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for one of the five Certified Nurse Aides (CNA) reviewed, CNA N.

Inspectors wroteThe facility reported a census of 43 residents. Based on interview and record review, the facility failed to ensure principles of antibiotic stewardship would be followed by nursing staff to ensure antibiotics used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner.

Inspectors wroteThe facility reported a census of 43 residents with 14 selected for review, which included six residents reviewed for accidents. The facility reported seven cognitively impaired mobile residents. Based on observation, interview and record review, the facility failed to ensure one Resident (R)12 transferred in a safe manner, and R15 shoelaces secured in a way to prevent entanglement in the wheelchair wheels. Furthermore, the facility failed to ensure the hydrocollator (a device that contains hot water that warms packs for application to areas to provide warm moist heat by therapy staff) used by therapy staff remained locked in the therapy room when staff were not in the area. [...]

Inspectors wroteThe facility reported a census of 43 residents with 14 selected for review, with two residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to review and revise the care plan for one Resident (R)12, that had an unplanned weight loss.

Inspectors wroteThe facility reported a census of 43 residents with 14 residents included in the sample, including three residents reviewed for Activities of Daily Living (ADLs). Based on observation, interview, and record review, the facility failed to ensure the three sampled, dependent Residents (R)16, R 17 had appropriate bathing opportunities and R 18, regarding shaving of facial hair.

Inspectors wroteThe facility reported a census of 43 residents with 14 selected for review, with two residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to ensure one Resident (R)12, received appropriate nutritional opportunities and interventions to prevent unintentional weight loss.

Inspectors wroteThe facility reported a census of 43 residents with 14 residents sampled, including six residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor two Residents (R)16 and R 17, regarding psychotropic (medication capable of affecting the mind, emotions, and behavior) medications, to ensure no unnecessary antipsychotic medication usage.

Inspectors wroteThe facility reported a census of 43 residents. Based on observation, record review and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, on a daily basis, for the 43 residents who reside in the facility.