Kansas Soldiers Home

Inspectors wroteThe facility identified a census of 51 residents. The sample included 12 residents, including one resident reviewed for pressure ulcers (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). Based on observation, interview, and record review, the facility failed to address and implement measures consistent with professional standards of practice to prevent the development of and promote the healing of pressure ulcers for Resident (R) 32 when staff failed to ensure R32 received pressure reducing interventions, repositioning, and physician involvement at the time the initial changes were identified. The resident developed Stage 3 pressure ulcers and was at risk for the development of new pressure ulcers, delayed healing, and worsening of existing ulcers.

Inspectors wroteThe facility reported a census of 51 residents. The facility identified five Certified Nurse Aides (CNA) employed for over 12 months during the review period. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for the five CNAs reviewed, to ensure adequate and appropriate care and services were provided to the residents of the facility. This placed the residents at risk for decreased quality of care.

Inspectors wroteThe facility reported a census of 51 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.

Inspectors wroteThe facility reported a census of 51 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. This placed facility residents at risk for insect or rodent infestation.

Inspectors wroteThe facility reported a census of 51 residents. The sample included 15 residents. Based on interviews, observation and record review, the facility failed to establish and maintain a consistent infection prevention and control program. Additionally 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 direct care to residents with catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), wounds, and/or surgical artificial openings entering the body to prevent the spread of infection. [...]

Inspectors wroteThe facility reported a census of 51 residents; the sample included 15 residents. Based on interview and record review, the facility failed to establish and infection prevention and control program which included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. This placed the residents at risk for infectious diseases.

Inspectors wroteThe facility had a census of 51 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to provide services to meet professional standards of care related to medication administration. This placed the residents at risk for medication-related complications and ineffective medication regimes.

Inspectors wroteThe facility reported a census of 51 residents. The sample included 15 residents. Based on observation, interview and record review the facility failed to ensure a medication error rate of less that five percent. 35 medication administration opportunities were observed, and 22 errors identified resulting in a medication error rate of 52.94 percent. This placed the residents at risk for medication related complications and ineffective medication regimes.

Inspectors wroteThe facility reported a census of 51 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observations, interview and record review the facility failed to obtain a consent form for a psychotropic 9alters mood or thoughts) medication for Resident (R) 3. This placed the residents at risk for adverse side effects of the medications and uninformed decisions.

Inspectors wroteThe facility reported a census of 51 residents; the sample included 15 residents. Based on observation, interviews, and record review, the facility failed to ensure an environment free from physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) when staff failed to assess and ensure safety regarding Resident (R) 28's use of a seatbelt on his motorized wheelchair. This deficient practice placed R28 at risk for complications related to restraints and impaired safety.

Inspectors wroteThe facility reported a census of 51 residents; the sample included 15 residents. Five residents were reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 1. This deficient practice placed R1 at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility reported a census of 51 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's monthly medication review (MRR) or document the rationale for Resident (R) 1. The deficient practice had the potential to lead to the residents receiving unnecessary medications.

Inspectors wroteThe facility reported a census of 51 residents with 14 residents sampled which included one resident reviewed for catheters, and three residents reviewed for respiratory care and services related to respiratory equipment. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services regarding catheter care for R 49 and respiratory care and services for R 2, R 11, and R21 to prevent cross contamination and infection.

Inspectors wroteThe facility reported a census of 51 residents with 14 selected for review. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident (R)21 and R11. This occurred with R21 when certified nurse aide (CNA) L entered R21's room without knocking, and R11 through the failure of the staff to place R11's call light within reach and R11's use of an air horn to alert staff to his need for assistance.

Inspectors wroteThe facility reported a census of 51 residents which included 14 selected for review. Based on interview and record review, the facility failed to fully complete comprehensive Minimum Data Set (MDS) assessment O-special treatments and programs and failed to complete Section V, Care Area Assessment Summary (CAA) for Resident (R)11 to include an analysis and rationale for care planned decisions. This placed the resident at risk for not accurately reflecting the resident's status and needs to develop an individualized comprehensive plan of care.

Inspectors wroteThe facility reported a census of 51 residents with a sample of 14 residents. Based on observation, interview, and record review, the facility failed to review and revise the care plan for Resident (R1) and R42, related to fall interventions.

Inspectors wroteThe facility reported a census of 51 residents with a sample of 14 residents, which included two residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to thoroughly investigate falls to determine contributing factors and causes of falls to implement appropriate immediate interventions to prevent further falls for resident (R)1 and R 42 with multiple falls.

Inspectors wroteThe facility reported a census of 51 residents with 14 residents sampled which included one resident reviewed for urinary catheters. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services regarding catheter care for one Resident (R)49, This deficient practiced placed R49 at risk for catheter related complications.

Inspectors wroteThe facility reported a census of 51 residents with 14 residents sampled, including three residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly store the nebulizer (a device for administering inhaled medications) and to correctly store distilled water used for oxygen humidification for to Resident (R)2, R11 and R21 in accordance with the standards of care. In addition, the facility failed to disassemble and clean the CPAP (continuous positive airway pressure - a machine used to provide continuous airway pressure in people diagnosed with obstructive sleep apnea [a condition in which a person cannot maintain an open airway while sleeping]) for R11.

Inspectors wroteThe facility reported a census of 51 residents, with 14 residents sampled. Based on observation, interview and record review, the facility failed to provide Resident (R2) a bed of appropriate size for the safety and convenience of the resident.

Inspectors wroteThe facility had a census of 51 residents. Based on record review and interview, the facility failed to provide the resident (or their representative), the correct Skilled Nursing facility Advanced Beneficiary Notices (SNFABN) Centers for Medicare Services (CMS) form 10055 to three of three residents reviewed, Resident (R)153, R9 and R12.

Inspectors wroteThe facility census totaled 31 residents with 12 included in the sample. Based on interview and record review the facility failed to complete and transmit a Discharge Minimum Data Set (MDS) assessments to the Centers for Medicare & Medicaid Services (CMS) in a timely manner for Resident (R)1.

Inspectors wroteThe facility reported a census of 31 residents with 12 sampled including five for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the pharmacist identified the lack of Abnormal Involuntary Movement Scale (AIMS) assessments completed per current standards of practice regarding potential side effects such as tardive dyskinesia (abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk) in the administration of antipsychotic medications for Resident (R)19. Findings Include: [...]

Inspectors wroteThe facility reported a census of 31 residents with 12 sampled including five for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the Abnormal Involuntary Movement Scale (AIMS, a periodically used clinical scale to aid in monitoring the potential side effects of antipsychotic medications) assessments were completed per current standards of practice regarding antipsychotic (medication which affects brain activities with mental processes and behavior) medications administered for Resident (R)19. Findings Include: [...]

Inspectors wroteThe facility reported a census of 31 residents, with one main kitchen. Based on observation, interview, and record review the facility failed to store foods in a safe and sanitary manner when dietary staff failed to date and reseal opened food items and failed to discard expired food items.