Tonganoxie Terrace

Inspectors wroteBased on record review, and interview, the facility failed to provide appropriate treatment and care for Resident (R) 1's peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) including monitoring the resident's status for complications, assessing PICC insertion site, performing PICC line flushes, and providing a sterile dressing change per the standards of care for a PICC line at least every seven days.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide Resident (R) 1 with the necessary behavioral health care and services, that included adequate supervision to prevent unwanted touching by R1 to other residents.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents, with one 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). Based on observation, record review, and interview, the facility failed to initiate effective interventions to prevent the development of the left lateral (pertaining to the side, away from the middle) foot and left middle toe facility acquired pressure ulcers for Resident (R) 44.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to inform the residents of the posting of the Ombudsman (an independent, neutral official who investigates, reports on, and helps resolve complaints) and State Agency contact numbers.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to inform the resident council of the state inspection report.

Inspectors wroteThe facility had a census of 70 residents. Based on observation, interview, and record review, the facility failed to conduct a thorough facility-wide assessment to determine necessary care for residents competently during both day-to-day operations and emergencies.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to place an open date on the Lantus (long acting insulin) pen (disposable, prefilled injection pen) in one of two nurse medication carts. The facility failed to consistently record refrigerator temperatures in the medication room. The facility further failed to lock an emergency (ER) cart, which had medications accessible to residents, with an expired Narcan (a medication that readily reverses an opioid, a narcotic pain medication).

Inspectors wroteThe facility had a census of 70 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner when dietary staff did not complete hair coverage with the hairnet and beard cover. This deficient practice placed the residents of the facility who received meals from the facility at risk for food borne illness.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern for 33 residents residing in the facility.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on record review and interviews, the facility failed to conduct a risk assessment to identify risks and implement a water management program to mitigate the risk of Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella) and other waterborne pathogens. [...]

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents, with five residents reviewed for immunizations, Resident (R) 16, R31, R43, R55, and R56, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, obtain an informed declination, or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC).

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents, with three residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 20 and R2 with written information regarding the facility's bed hold policy when the residents were transferred to the hospital and failed to notify the State Long Term Care Ombudsman (LTCO) of their facility-initiated discharge to the hospital.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent further injuries to the lower extremities of Resident (R) 3 and R44's smoking activity.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide necessary services for two of six residents reviewed for activities of daily living (ADL): Resident (R) 69 and R20.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide care and treatment in accordance with professional standards of practice when the staff failed to provide Resident (R) 6 treatment for low blood sugar before transferring to the hospital. The facility failed to provide documentation related to R3's and R20's transfer to the hospital.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to fully investigate Resident (R) 25's unwitnessed fall to identify causative factors and implement interventions to prevent further falls. The facility further failed to accurately identify R44's tobacco use and assess his ability to safely smoke independently.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to establish and implement a system to accurately reconcile the disposition of controlled medications and failed to account for all controlled substances.

Inspectors wroteThe facility identified a census of 67 residents. The sample included nine residents, with two residents reviewed for involuntary discharge. Based on record review and interviews, the facility failed to include the required information on an emergency discharge notice for Resident (R) 1 and on a 30-day discharge notice for R2. This deficient practice had the risk for miscommunication between the facility and resident/family, a possible missed opportunity for healthcare services, and involuntary discharge for R1 and R2.

Inspectors wroteThe facility identified a census of 67 residents. The sample included nine residents, with three residents reviewed for discharge. Based on record review and interviews, the facility failed to document a recapitulation of stay for Residents (R) 2, R3, and R4. This deficient practice had the risk for miscommunication of services received during the stay in the facility and if post-discharge care needs for the affected residents.

Inspectors wroteThe facility identified a census of 67 residents. The sample included nine residents, with three residents reviewed for bathing. Based on observations, record review, and interviews, the facility failed to provide consistent bathing for Residents (R) 5 and R6. This deficient practice had the risk of poor hygiene and decreased self-esteem and dignity for the affected residents.

Inspectors wroteThe facility had a census of 85 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). The facility further failed to ensure adequate infection control practices related to catheter (a tube inserted into the bladder to drain urine) care. These deficient practices placed the residents at increased risk for transmission of infectious diseases.

Inspectors wroteThe facility had a census of 85 residents, with 18 residents included in the sample. Five nurse aide staff were reviewed for the required training. Based on observation, record review, and interview, the facility failed to provide the required 12 hours of in-service education for Certified Medication Aide (CMA) R, CMA RR, and CMA SS. This deficient practice placed the residents at risk of receiving impaired care.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure an environment free from preventable accident hazards for Resident (R) 29 who burned his fingers his fingers while smoking. The facility further failed to assess R41 for the ability to smoke safely and failed to provide interventions to prevent injuries and falls for R46 and R31. These deficient practices placed the residents at risk for injuries related to accidents.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents, with eight reviewed for unnecessary medications. Based on observation, record review, and interview, the Consultant Pharmacist (CP) failed to identify and report medications administered outside of physician-ordered parameters for Resident (R) 15, R31, and R6 and failed to identify and report an inappropriate indication for Seroquel (an antipsychotic medication used to treat severe mental disorders) for R4. This placed the residents at risk for adverse side effects, physical decline, and unnecessary medications.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to date Resident(R)34 and R13's insulin (a hormone that allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R38's insulin flex pen when outdated. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents with four reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified injuries of unknown origin as potential allegations of abuse and report to the administrator to investigate. This placed the residents at risk for unidentified and ongoing abuse and/or mistreatment.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R)46's injuries of unknown origin to rule out possible abuse or neglect. This placed the residents at risk for unidentified and ongoing abuse or neglect.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to develop comprehensive care plans for Resident (R)31, R77, and for R29. This placed the residents at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to review and revise the care plan with interventions to address Resident (R) 30's pain and R46's skin tears. This deficient practice placed R30 and R46 for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview the facility failed to provide necessary services to maintain good personal hygiene including bathing for Resident (R) 4, R41, and R30. This placed the residents at risk for impaired health and decreased psychosocial well-being.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents with five reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) or urinary tract infection (UTI-an infection in any part of the urinary system). Based on observation, interview, and record review the facility failed to provide care and services to prevent potential infection of the urinary system for Resident (R) 29 and R17 during care for their urinary catheters and failed to promote dignity with a privacy bag. This deficient practice placed R29 and R17 at risk for urinary infections and other catheter-related complications.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents with one reviewed for pain. Based on observation, interview, and record review the facility failed to provide non-medicinal pain relief measures and promote effective pain management for Resident (R) 30, who experienced almost constant severe pain. This deficient practice placed R30 at risk for ongoing severe pain and impaired quality of life.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial well-being for Resident (R)26 and R77. This placed the residents at risk for decreased quality of life.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents, with eight reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to notify the physician of blood sugars outside of ordered parameters for Resident (R) 31 and further failed to monitor R31's blood pressure before administration of medication for high blood pressure. The facility failed to hold blood pressure medication and insulin (medication that lowers the level of glucose [a type of sugar] in the blood) when the medication was out of the physician-ordered parameters for R6. This placed the residents at risk for adverse effects related to medication.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents, with eight reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)4's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R4 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.

Inspectors wroteThe facility had a census of 85 residents. The sample included 18 residents with eight reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 15. This deficient practice placed the resident at risk for adverse medication reactions and physical decline.

Inspectors wroteThe facility had a census of 68 resident. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food in a sanitary condition for the 68 residents who resided in the facility and received meals from the facility kitchen, placing them at risk for food borne illness.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents. Based on observation, record review and interview the facility failed to ensure their (QAA) Quality Assessment and Assurance Committee adequately identified deficient areas of practice and to develop and implement appropriate plans of action to correct the deficient practices for the 68 residents residing in the facility.

Inspectors wroteThe facility had a census of 68 residents. Based on observation, record review and interview the facility failed to adhere to infection control policies during an outbreak of COVID-19 (highly contagious, potentially life-threatening respiratory virus), which placed the resident and staff at risk for possible exposure of respiratory illness.

Inspectors wroteThe facility had a census of 68 residents. Based on interview and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) completed the specialized training in infection prevention and control.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to notify the physician for Resident (R) 30, who had multiple days of refusing her medications for several months; R47, who had a history of seizures (a sudden, uncontrolled electrical disturbance in the brain) and had an unresponsive episode; R37, who had a history of sexual behavior and had an alleged incident with another resident, and R59, who had an unresponsive episode in the shower. This placed the resident's at risk for further physical, emotional, and mental decline.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents with eight residents reviewed for activities of daily living (ADL's). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing for seven of the eight residents reviewed for ADLs, Resident (R)8, R55, R19, R23, R30, R67 and R15. This placed the residents at risk for poor personal hygiene.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to properly date and store insulin pens (medications used to treat a chronic condition that affected the way the body processed blood sugar) label, and failed to store drugs and biologicals at a safe room temperature in the south hall medication room. This deficient practice had the risk of physical complications and ineffective treatment for affected residents.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents of which five where reviewed for immunization status. Based on record review and interview the facility failed to offer and provide and/or obtain informed refusals for Influenza and Pneumococcal vaccinations for Resident (R) 15, R25, R39, R67 and R47. This placed the affected residents increased risk for illness and infection.

Inspectors wroteThe facility identified a census of 68 residents. The sample included 21 residents with five residents reviewed for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccination review. Based on record reviews and interviews, the facility failed to offer and administer or obtain a signed declination for the COVID-19 booster vaccination for Resident (R) 15, R25, R39, R67 and R47. This deficient practice placed the residents at increased risk for unwarranted complications related to COVID-19 and the risk to spread illness and infection to the residents.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents. Based on record review and interview, the facility failed to provide three sampled residents, Resident (R) 39, R49 and R320 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services. This placed the residents at risk to make uninformed decisions about their skilled care

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to develop a care plan for Activities of Daily Living (ADLs) for Resident (R) 47. This placed the resident at risk for unmet care needs.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents of which three were reviewed for falls and behaviors. Based on observation, record review, and interview, the facility failed to revise Resident (R)30's care plan for medication refusals and failed to place resident centered interventions to prevent falls on the care plan for R47 and R15. This placed the residents at risk for physical and mental injury due to unmet care needs.

Inspectors wroteThe facility had a census of 68 resident. The sample included 21 residents. Based on observation, record review and interview, the facility failed to provide staff support to assist and maintain activities of daily living for Resident (R) 15, which placed the resident at risk for decline and injury.

Inspectors wroteThe facility identified a census of 68. The sample included 21 residents with two residents reviewed for quality of care. Based on observation, interviews and record review the facility failed to ensure staff provided assessment, ongoing monitoring and physician involvement for Resident (R) 59 who had an unresponsive episode and R47 who had seizure activity. This placed the residents at increased risk for physical complication, unidentified adverse outcomes, and delayed treatment. Findings Included: [...]

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to investigate a root cause analysis to prevent falls for two of four residents reviewed for falls, Resident (R) 15 and R47. This deficient practice placed the resident at risk for further falls and injury.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents with six residents reviewed for nutritional status. Based on observation, record review, and interview, the facility failed to monitor, address and ensure interventions and assistance was provided to prevent a continued weight loss for Resident (R) 15, who required assistance with eating. This placed R15 at risk for continued unintentional weight loss and impaired nutritional status.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents, with one reviewed for dialysis (process of removing 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 interview, the facility failed to perform physical assessments on Resident (R) 23, after his return from dialysis. This placed the resident at increased risk for unidentified complications related to dialysis or delay in treatment.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents with three reviewed for behavioral and/or emotional status. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R)30. This placed the resident at risk for unaddressed and ongoing behavioral health issues and impaired psychosocial wellbeing. Findingls inlcuded: [...]

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents, with one reviewed for medication availability. Based on record review and interview, the facility failed to ensure availability of physician ordered medications for Resident (R)321. This placed the resident at risk for ineffective medication regimen and physical decline.

Inspectors wroteThe facility at a census of 68 residents. The sample included 21 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 59 consistently received medications as ordered by the physician and failed to follow up on consistent refusal of physician ordered medications for R30. This placed the residents at increased risk for ineffective medication therapy.

Inspectors wroteThe facility had a census of 68 residents. The sample included 21 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for Resident (R)8's Seroquel (an antipsychotic -medication used to treat any major mental disorder characterized by a gross impairment in reality testing), failed to report to ther physician multiple refusals of R30's psychotropic (altering mood or though) medication and failed to monitor behaviors for R59 who received multiple psychotropic medication including an antipsychotic. This placed the residents at increased risk for negative side effects related to medications and unnecessary psychotropic medication use.