Kaw River Care and Rehab

Inspectors wroteBased on interviews, observations, and record review, the facility failed to assist Resident (R) 1 in getting transportation set up to take R1 to her radiology appointment.

Inspectors wroteThe facility had a census of 36 residents. The sample included three residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure that cognitively impaired Resident (R) 1 remained free from injuries of unknown origin. On 06/07/25, R1 sustained a second-degree burn (potentially painful burn which affects the first and second layer of the skin) of unknown origin to his left arm and shoulder. This deficient practice also placed R1 at risk for further injuries, pain, abuse, neglect, and/or mistreatment.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents, with five residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 32 when staff transferred R32 with the assistance of one staff instead of two, and failed to use a gait belt (belt used to help transfer or stabilize during activity). This deficient practice resulted in a fall that caused a fracture (broken bone). The facility also failed to implement new fall interventions for R11. This placed R32 and R11 at risk for preventable falls and related injuries.

Inspectors wroteThe facility identified a census of 37 residents. The sample includes 12 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents, four Certified Nurse Aides (CNAs), and one Certified Medication Aide (CMA) who were sampled for performance reviews. Based on record review and interview, the facility failed to complete the required nurse aide performance review at least once every 12 months. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility had a census of 37 residents. Based on observation, interview, and record review, the facility failed to date three insulin pens when opened, ensure medications were secure when unattended, and failed to remove expired medication from use. This deficient practice placed residents who may have received those medications at risk for ineffective medication.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation and interview, the facility failed to ensure that residents ' rights and dignity were respected by staff when staff failed to provide a dignity bag for Resident (R) 12's indwelling catheter (tube placed in the bladder to drain urine into a collection bag) bag. This placed R12 at risk for decreased self-esteem and decreased self-worth.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 11, had a time limit of 14-days for his as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication order for Ativan (lorazepam: benzodiazepine medication used to treat anxiety, insomnia (trouble sleeping), severe agitation, and active seizures (violent involuntary series of contractions of a group of muscles)including status eplielticus), and further failed to ensure R32 had a time limit of 14-days for PRN anti-anxiety Ativan with a physician indication of use. This defiant practice placed R11 and R32 for potentially unnecessary psychotropic (alters mood or thought) medication administration. Findings Included: [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to report to the State Agency (SA) as required when a Resident (R) 32 had a fall that resulted in a major injury. This placed R32 at risk for ongoing neglect and abuse.

Inspectors wroteThe facility had a census of 37 residents, with 12 sampled, including two residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide a Bed Hold Notice to Resident (R) 18 or her representative, upon transfer and admission to a hospital. This deficient practice placed R18 at risk for not being permitted to return and resume residence in the nursing facility. The facility further failed to provide a written notification of transfer to R12 or the resident's representative as soon as practicable, which included the required information.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure staff developed and implemented a comprehensive care plan for Resident (R) 29 that included staff direction for activities of daily living (ADL) care. This placed R29 at risk of impaired care due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to revise the comprehensive care plan to include interventions for falls for Resident (R) 11. This defiant practice placed R11 at increased risk for future falls.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to assess or provide a restorative range of motion for Resident (R) 16. This deficient practice placed the resident at risk for discomfort, stiffness, and the possibility of forming contracture (abnormal permanent fixation of a joint or muscle).

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure that the daily posted nurse staffing data included the facility census.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents, who were reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider. This deficient practice created a risk for missed or delayed services and impaired care for Resident (R) 30 and R25. Findings Included: [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included six residents. Based on record review, observations, and interviews the facility failed to provide care and services that promoted resident dignity for Resident (R) 1. This placed R1 and other residents in the vicinity at risk for impaired dignity and decreased quality of life.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure that there was a registered nurse (RN) on staff for at least eight consecutive hours, seven days a week. This deficiency had the potential for poor quality of care and negative outcomes for the residents.

Inspectors wroteThe facility identified a census of 32 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food and kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to consistently provide facility directed weekend activities to the cognitively impaired residents unable to self direct. This deficient practice had the risk for a decline in psychosocial well-being.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. This deficient practice placed the 12 residents at risk for preventable injuries and accidents. Findings Included: - On 08/22/23 at 07:04AM an initial walkthrough of the facility was completed. An inspection of the supplemental oxygen storage room revealed no lock or mechanism to secure the room's contents from opening the door. The room contained 20 full cylindrical oxygen cannisters stored in the rack with the room. Licensed Nurse (LN) G stated the door should be locked but she was not sure if it could be. LN G stated she would notify Administrative Nurse D. [...]

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents. Based on observations, record reviews, and interviews, the facility failed to ensure there was a sufficient number of nursing staff to provide care and to respond to each resident's basic needs and individual needs. This deficient practice had the potential for physical or psychosocial harm.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents. Based on record review, observations, and interviews, the facility failed to maintain sanitary infection control practices related to indwelling catheters (tube inserted into the bladder to drain urine into a collection bag), wound care, laundry services, and medication administration. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 08/22/23 at 07:05AM an inspection of the Main Hall revealed the soiled utility room was unsecured. On 08/22/23 at 07:10AM an inspection of the unsecured West Hall shower room revealed an overfilled trashcan next to the toilet with soiled incontinence products. On 08/22/23 at 07:59AM observation revealed soiled linen on the floor of Resident (R)6's room. [...]

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interviews the facility failed to provide care in a respectful, dignified manner for Resident (R) 6 when staff failed to close the door to his room, to ensure privacy, while staff assisted him in changing his clothes and for R25, when staff performed personal cares without ensuring total privacy. This placed the residents at risk for impaired dignity and quality of life.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R)180. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on observation, interview and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R)180 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital. This placed the resident at risk for impaired rights

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension)/mobility). Based on observation, record review, and interviews, the facility failed to create a comprehensive care plan to address restorative services for Resident (R) 9, which placed him at risk of loss of ability to perform activities of daily living (ADLs) and development of contractures (abnormal fixation of a joint or muscle) due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with two reviewed for 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) care. Based on observations, record reviews, and interviews, the facility failed to ensure appropriate application of Resident (R)25 pressure relieving boots, failed to ensure repositioning which included ensuring feet were not pressed into the footboard, and failed to provide wound care per standards of practice. This deficient practice placed R25 at risk for complication related to skin breakdown and pressure ulcers.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension)/mobility. Based on observation, record review, and interviews, the facility failed to provide services to prevent a potential decrease in ROM/mobility and/or worsening of contractures (abnormal fixation of a joint or muscle) for Resident (R) 9, which placed him at risk of loss of ability to perform activities of daily living (ADLs) and development of contractures.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with three reviewed for incontinence care. Based on observations, record reviews, and interviews, the facility failed to provide appropriate indwelling urinary catheter (tube inserted into the bladder to drain urine into a collection bag) care and placement per standards of practice for Resident (R)25. This deficient practice placed R25 at risk for complication related complications.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, interview, and record review, the facility failed to assess and document arteriovenous (AV-a surgically created connection between artery and a vein used for hemodialysis) fistula for infection or bleeding every day and failed to obtain communication from the dialysis center and assess post dialysis for Resident (R) 81. This deficient practice placed R81 at risk for complications related to dialysis.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding lack of dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 80, no duration for as-needed psychotropic (alters mood or thought) medication for R80 and R81. The CP also did not identify medication administered outside the physician ordered parameters for antihypertensive (class of medication used to treat hypertension (high blood pressure) medications for R9. This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 80. The facility also failed to identify medication administered outside the physician ordered parameters for antihypertensive (class of medication used to treat hypertension (high blood pressure) medications for R9 and the lack of monitoring antihypertensive medication as physician ordered for R2. This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with five residents reviewed unnecessary medications. Based on observation, record review, and interviews, the facility failed to provide a 14-day stop date, intended duration of therapy, and rationale for extended use related to Resident (R)24 and R80's PRN (given as needed) lorazepam (antianxiety medication that calms and relaxes people with excessive anxiety, nervousness, or tension) medication and R81's PRN trazodone (antidepressant medications used to treat mood disorders and relieve symptoms of depression) medication. This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure necessary information regarding Resident (R)24's care between the nursing home and hospice was availabale and known to all staff 24-hours a day, seven days a week including documentation of a description of the services, medication, and equipment provided to R24 by hospice. This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial needs for R24. Findings Included: [...]

Inspectors wroteThe facility identified a census of 33 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to provide mail services on Saturdays.

Inspectors wroteThe facility identified a census of 33 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility failed to submit accurate staffing hour data for all licensed nursing personnel.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to obtain food temperatures at meal times, placing the residents at risk for food borne illness.

Inspectors wroteThe facility had a census of 40 residents with seven Covid (highly contagious and potentially fatal respiratory disease) positive residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to implement core principles of infection control practices concerning Covid when the facility failed to ensure staff were screened for signs and symptoms of Covid prior to reporting to duty in resident care areas. The facility further failed to ensure multi-use equipment was cleaned between use and failed to ensure availability of hand hygiene at screening station used by staff and visitors. The facility failed to ensure staff practiced acceptable hand hygiene measure when passing ice and delivering linens to residents' rooms. This placed the residents who resided at the facility at risk for infections.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with six reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing services for six sampled residents, Resident (R)9, R21, R30, R137, R33, and R17. This placed the residents at risk for poor hygiene.

Inspectors wroteThe facility had a census of 40 residents. The sample included 22 residents, with 5 reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to follow the facility's Consultant Pharmacist's recommendation regarding charting of behaviors and side effects of psychotropic medication for four sampled residents, Resident (R) 9, R21, R25, and R27.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor behaviors and side effects for four sampled residents who received psychotropic medications (medications that affect mental function and behaviors), Resident (R) 9, R21, R25, and R27. This placed the residents at risk for adverse effects and increased behaviors.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on record review and interview, the facility failed to administer a pneumococcal immunization for four of six residents, Resident (R) 18, R27, R14, and R33, and failed to review and document immunization status for one of six residents, R137, reviewed for immunization status placing the residents at increased risk for infections.

Inspectors wroteThe facility had a census of 40 residents with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide a completed Centers for Medicare Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) 10055 form to include estimated daily skilled service cost for three of three samples residents (or their representatives), Resident (R) 2, R8, and R17. This placed the residents (or representatives) at risk to make uninformed decisions for their Medicare skilled services.

Inspectors wroteThe facility had a census of 40 residents. The sample included 40 residents, with one reviewed for baseline care plan. Based on observation, record review, and interview, the facility failed to develop a baseline care plan for one sampled resident, Resident (R) 89, who was a new admission. This placed R89 at risk for inappropriate care.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, with one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to complete a discharge summary for Resident (R) 36 that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) summary of the resident's stay in the facility. This placed R36 at risk for miscommunication or interruption in the continuum of care.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure staff possessed the necessary skills and competencies necessary to assure the highest level of resident care when staff failed to assess or test Resident (R) 18 who had a change of condition and exhibited signs and symptoms of Covid (highly contagious and potentially fatal respiratory virus). This placed R18 at risk for unmet needs. Findings Included: [...]

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents with one reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide resident specific care for behaviors related to dementia and documenting of behaviors for Resident (R) 33, placing the resident at risk for impaired psychosocial and physical wellbeing.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents with one reviewed for hospice (care provided for the terminally ill). Based on observation, record review, and interview, the facility failed to collaborate care with the hospice provider for Resident (R) 27. This placed R27 at risk for unmet palliative (therapy designed to relieve or reduce intensity of uncomfortable symptoms) care needs.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift.