Kiowa Hills Rehabilitation and Nursing, LLC

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#15, #9, and #11) of five residents were free from abuse out of 15 sample residents. Specifically, the facility failed to:-Protect Resident #15 from sexual abuse by Resident #5;-Protect Resident #9 from sexual abuse by Resident #14; and,-Protect Resident #11 from physical abuse by Resident #12.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision for one (#13) of three residents reviewed for accidents out of 15 sample residents. Specifically, the facility failed to ensure Resident #13 was provided safe transportation in the facility's van.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#1) of three residents with limited range of motion receive appropriate treatment and services out of seven sample residents. Specifically, the facility failed to ensure Resident #1 received restorative services according to the physical therapy recommendations.

Inspectors wroteBased on observations and interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to ensure:-Hand hygiene was conducted appropriately;-Food was held at the correct temperature; and,-Room trays were covered during transportation from the kitchen to the residents' room.

Inspectors wroteBased on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and follow up with residents who attended food committee and resident council on the outcomes and resolutions of grievances expressed regarding food.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure recipes were followed to meet the residents' nutritional needs. Specifically, the facility failed to follow the correct portion sizes to ensure adequate nutrition was provided to the residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents consistently receive food prepared by methods that conserve nutritive value, palatable in taste, texture and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#1 and #2) of four residents reviewed for abuse out of 16 sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #1 and Resident #2 from physical abuse by Resident #3.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene for one (#11) of three residents reviewed for ADLs out of 16 sample residents. Specifically, the facility failed to ensure Resident #11 was repositioned and provided with incontinence care in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#4) of three residents reviewed out of 16 sample residents. Specifically, the facility failed to ensure physician's orders were followed for Resident #4's wound care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured residents received adequate supervision and assistance to prevent a fall with major injury for one (#38) of three residents reviewed for accidents/hazards out of 33 sample residents. Resident #38, who was at high risk for falls and had a history of a fall with a fracture, was admitted to the facility on [DATE] and readmitted on [DATE] after a hospital stay for repair of a right femur fracture. Per the resident's fall care plan, staff were instructed to anticipate and meet the resident's needs, keep the call light within reach and keep personal items within reach. Resident #38 experienced a witnessed fall on 12/20/24 while trying to walk to her sink to get a drink of water, resulting in a fracture of her right femur. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, satellite kitchen, and one of two nourishment refrigerators. Specifically, the facility failed to: -Ensure ready to eat foods were handled in a sanitary manner to prevent cross contamination in the main kitchen; -Ensure safe and appropriate storage of food items in the kitchen and nourishment room refrigerators; -Ensure proper hair restraints were worn in the kitchen; -Ensure the kitchen and food service areas were kept clean; and, -Ensure frozen meats were thawed in a safe manner.

Inspectors wroteBased on record review, observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease. Specifically, the facility failed to: -Wear the appropriate personal protective equipment (PPE) when entering transmission based precaution rooms; -Offer updated COVID-19 vaccinations and document consent or declination for vaccination for Residents #16, #36, #205 and #255; -Ensure staff followed proper hand hygiene practices during meal delivery; -Ensure staff followed proper infection prevention practices during wound care for Resident #37; and, -Ensure resident's glucometers were disinfected after each use.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for three (#5, #14 and #38) of five residents out of 33 sample residents. Specifically, the facility failed to invite and conduct regular care conferences to review the resident's plan of care with Resident #5, Resident #14 and Resident #38.

Inspectors wroteBased on observations and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on four of five neighborhoods. Specifically, the facility failed to maintain a comfortable air temperature range on four out of five neighborhoods.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents were provided services that meet professional standards for five (#1, #205, #255, #46 and #4) of nine residents out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and Resident #205 received medications in a timely manner according to the physician's orders; and, -Ensure lancets were used instead of a syringe with a needle to check blood sugar levels for Resident #205, Resident #255, Resident #46 and Resident #4.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts and one of one medication storage room. Specifically, the facility failed to: -Ensure expired medications were removed from the medication carts and medication storage room; and, -Ensure over the counter medications intended for use by a single resident were labeled with the resident's name.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#5) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #5 was provided beverages of his choice when requested; and, -Ensure Resident #5 was provided clothing when he requested to get dressed and was not dressed in a hospital gown.

Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for one (#46) of two residents out of 33 sample residents. Specifically, the facility failed to honor Resident #46's preference for assistance with bathing from female shower aides.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents and their representatives were provided prompt efforts by the facility to resolve grievances for one (#14) of four residents out of 33 sample residents. Specifically, the facility failed to document and follow-up on grievances reported by Resident #14 regarding a missing blanket and socks.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#16) of three residents reviewed for activities out of 33 sample residents received an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being. Specifically, Resident #16 was not provided with meaningful activities or one-to-one staff visits per his individualized plan of care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#17) of two residents reviewed for hospice services out of 33 sample residents. Specifically, for Resident #17, the facility failed to: -Obtain a physician's order for hospice care; -Ensure the hospice agency's notes were easily accessible to the facility staff and had consistent communication and documentation of hospice care visits and updates; and, -Initiate a hospice care plan timely.

Inspectors wroteBased on interviews, observations and record review, ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to: -Ensure resident food was palatable in taste, temperature, texture and appearance; and, -Address resident food complaints.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; -Hand hygiene practices were followed during meal preparation; -Kitchen and food service areas were kept clean; and, -Staff were familiar with the sanitation process of the dishwashing machine to ensure proper sanitation level was being reached during use.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify concerns and or implement effective action plans to mitigate the repetition facility failures in resident rights, quality of care, pharmacy services, food and nutrition services, infection control and physical environment.

Inspectors wroteBased on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning environment, choices and personal items.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 23 of 50 resident rooms in five hallways. Specifically, the facility failed to ensure: -Walls, baseboards and doors were properly maintained, and rooms were cleaned and free of mice droopings; and, -Comfortable room temperature levels for all rooms in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure environment were free of accidents and hazards. Specifically, the facility failed to: -Ensure space heaters temperatures were mointored for resident safety; -Ensure hot liquids were mointored for resident safety; -Ensure loose medications were not in the room for Resident #27; and, -Ensure Resident #6 was provided the interventions available to prevent falls.

Inspectors wroteBased on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, facility assessments, and described in the plan of care for four of four licensed practical nurses (LPNs) and two of two registered nurses (RNs). Specifically, the facility failed to: -Complete competencies as identified on the licensed nurse competency checklist for LPN #1, #2, #3 and #5; and, -Complete competencies as identified on the licensed nurse competency checklist for RNs #1 and #4.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for four (#6, #23, #27 and #9) of five residents reviewed for unnecessary medications out of 27 sample residents. Specifically, the facility failed to: -Accurately track behaviors for the continued use of psychotropic medication for Resident #6. -Follow pharmacist recommendations for gradual dose reductions of psychoactive medications for Resident #23 and #27; -Identify non-pharmacological interventions on psychotropic medication behavior trackers for Residents #23 and #27; -Ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #27; [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure four (#23, #31, #9 and #6) of six residents were free of significant medication errors out of 27 sample residents. Specifically, the facility failed to: -Complete the medication administration records for Residents #23, #31, and #9 to reflect if a medication was administered; -Notify the physician of missed doses of medication for Resident #6; and, -Notify the physician when a medication was administered outside of the order instructions for Resident #6.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards in three of five medication carts. Specifically, the facility failed to: -Date a Trilegy inhaler when opened; -Date and identify the owner of an Ozempic pen; -Date an Anoro ellipta inhaler; -Date an Fluticasone propion-salmeterol diskus inhaler; and, -Date an open Budesoride inhaler when opened.

Inspectors wroteBased on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included the use of wanderguards and staff competencies.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning on the 300 hall out of five halls resident halls.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a mice infestation in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#6) of three residents reviewed for the use of supplemental oxygen out of 27 sample residents. Specifically, the facility failed to ensure oxygen was provided as ordered for Resident #6.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain and maintain the highest practicable mental and psychosocial wellbeing for one (#23) of three residents reviewed out of 27 sample residents. Specifically, the facility failed to monitor and provide an ongoing assessment as to whether care approaches were meeting the emotional and psychosocial needs for Resident #23.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#42) of one resident reviewed for hospice services out of 27 sample residents. Specifically, the facility failed to orientate hospice aides to the facility including the policies and procedures for Resident #42.

Inspectors wroteBased on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 for one of five isolation rooms. Specifically, the facility failed to don (put on) personal protective equipment (PPE) prior to entering a resident's room who was COVID-19 positive.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food under sanitary conditions in the kitchen. Specifically, the facility failed to ensure: -The kitchen and food service areas were kept clean; -Frozen and perishable food was stored properly and off the floor for a long period of time; and, -Staff was familiar with the sanitation process of the dishwashing machine to ensure proper sanitation level was being reached during use.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide an effective pest control program to ensure the facility was free of pests which impacted all residents residing in the facility. Specifically, the facility failed to take the appropriate measures to control a mice infestation in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure staff knocked before entering resident rooms.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure one (#2) of three residents reviewed for activities of daily living out of 10 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to ensure Resident #2, who was a dependent resident, received incontinence care timely.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 in five of five halls. Specifically, the facility failed to: -Ensure face coverings were worn by staff while providing care; -Ensure resident bedrooms were cleaned with proper infection control techniques; -Have a water plan to prevent Legionella disease; -Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; and, -Ensure resident equipment was cleaned between uses.

Inspectors wroteBased on interviews and record review, the facility failed to test residents, facility staff, and individuals providing services under arrangement and volunteers for COVID-19. Specifically, the facility failed to ensure: -Rapid point-of-care (POC) tests for COVID-19 were consistently conducted on staff prior to the start of their shift, based on the facility's county positivity rate; and, -Polymerase chain reaction (PCR) testing was not completed on all staff based on county positivity rate and outbreak status.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to monitor each contracted staff member's vaccination status to ensure proper advanced PPE (personal protective equipment) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure four (#17, #40, #19 and #61) of four out of 35 sample residents, had the right to participate in the development and implementation of his or her person-centered plan of care. Specifically, the facility failed to inform and invite residents and/or responsible parties to participate in care plan meetings for Resident #17, #40, #19 and #61.

Inspectors wroteBased on observations and interviews the facility failed to ensure residents had the right to visitation for two (#40 and #35) residents out of 35 sample residents. Specifically, the facility failed to allow the residents to have visitors at the time of their choosing.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 16 of 49 resident rooms, five of five hallways. Specifically, the facility failed to ensure walls, baseboard cove, doors, floor tiles, and ceiling were repaired, painted and properly maintained: and failed to ensure resident's had clean bath linens.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#17 and #26) of three out of 35 sample residents with limited range of motion (ROM) received appropriate treatment and services. Specifically the facility failed to: -Ensure preventative measures were put into place to prevent a decrease in ROM for Resident #26 and #17; and -Ensure a restorative nursing program was established for the continuity of care for Resident #17's right hand contracture.

Inspectors wroteBased on observation and record review the facility failed to ensure residents were as free from accident hazards as possible for four (#55, #36, #16, and #26) out of 35 sample residents. Specifically, the facility failed to ensure: -A smoking apron was documented as a care plan intervention for Resident #55; -Resident #36's inhaler was kept in a secure place; -Resident #16's over the counter medications were secure; -Resident #26 received nectar thick liquids; and, -A tube feeding device was plugged into a medical electrical outlet power strip.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in two medication carts and one storage room out of four medication carts and one storage room. Specifically the facility failed to: -Ensure medications were labeled with open dates; -Ensure the oral medications were stored in a separate location from inhaled medications; -Ensure loose medications in carts were properly disposed; -Ensure narcotic medications were disposed of when the packaging was compromised; -Ensure expired medications were removed from the medication cart or medication rooms; -Ensure the temperature of the refrigerator was kept within a safe range; and, -Ensure the facility did not use a dormitory style refrigerator freezer combination in the medication room. I. [...]

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture and temperature.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#36) out of 35 sample residents. Specifically, the facility failed to conduct a self-administration assessment for Resident #36 to carry and administer an inhaler without staff assistance. Cross-reference F689: the facility failed to ensure an inhaler was not left out in a resident area unattended.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide services by qualified persons for three (#48, #18 and #44) out of 35 sample residents. Specifically, the facility failed to ensure Residents #48, #18 and #44 were assessed by a registered nurse (RN) following a fall.

Inspectors wroteBased on observation, record review and interviews, the facility failed to consistently provide activities of daily living (ADLs) support for two (#54 and #26) of six dependent residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to: -Provide eating assistance for Resident #54; and, -Provide timely repositioning and oral care for Resident #26.

Inspectors wroteBased on observations, record review and interviews the facility failed have an ongoing activity program designed to meet the needs of one (#49) out of five reviewed for activities out of 35 sample residents. Specifically, the facility failed to provide person-centered activities that met the interest and needs of Resident #49.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two (#19 and #48) out of 35 sample residents. Specifically, the facility failed to ensure: -A treatment order was in place for an open area for Resident #19; and, -Neurological checks were completed post fall with a head injury for Resident #48.

Inspectors wroteBased on observations interviews and record review the facility failed to provide podiatry services for one resident (#16) out of two reviewed for podiatry services out of 35 sample residents. Specifically, the facility failed to ensure Resident #16's toenails were trimmed timely.

Inspectors wroteBased on observations, resident interview, record review, and staff interviews, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for one (#49) of one resident reviewed for catheters of 35 sample residents. Specifically, the facility failed to: -Ensure the resident's urinary catheter down drain bag was kept from dragging on the floor; and, -Ensure the resident's urinary catheter was kept below the bladder.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide ostomy care to one resident (#40) out of 35 sample residents. Specifically, the facility failed to have order in place to provide ostomy care for Resident #40.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one (#48) of three residents reviewed for nutrition/hydration, out of 35 sample residents, maintained acceptable parameters of nutritional status to avoid unintended weight loss. Specifically, the facility failed to address Resident #48's weight loss.

Inspectors wroteBased on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#163) of two residents reviewed for supplemental oxygen use out of 35 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #163.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#163) of two residents reviewed for hospice services out of 35 sample residents. Specifically, the facility failed to: -Have a written agreement for Resident #163 that included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on a hose in the maintenance closet, increasing the risk of contamination to the facility's main water supply.