Via Christi Village Hays Ks LLC

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide restorative therapy services to ensure Resident (R) 3, R4, R5, R6, and R7 maintained or improved mobility with the maximum practicable capability.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide sufficient nurse staffing to ensure Resident (R) 3, R4, R5, R6, and R7 were provided with the restorative services designed to improve their abilities to the highest practicable level. (Refer to F688)

Inspectors wroteBased on interviews and record review, the facility failed to implement the policy to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure Certified Nurse Aides (CNAs) had sufficient training to ensure Residents (R) 1 and R2 received quality care in accordance with standards of practice.

Inspectors wroteThe facility identified a census of 84 residents, with 10 residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to follow R49's care plan and failed to transfer R49 with a full lift, which placed R49 at risk for injury. On 06/04/25, two unidentified Certified Nurse's Aides (CNAs) transferred R49 by lifting her under her arms and pivot transferred R49 from her wheelchair to the shower chair. R49's left foot, which had a non-skid slipper on it, caught on the floor and her left knee twisted during the transfer. R49 sustained a left nondisplaced medial tibial plateau fracture (a break in the shinbone at the knee joint). On 06/11/25 two unidentified CNAs transferred R49 again by lifting her up under her arms and pivot transferred R49 from her wheelchair to the shower chair. [...]

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents. Based on observation, interview, and record review, the facility failed to employ a full-time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 84 residents of the facility at risk for inadequate nutrition or foodborne illness.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to store food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 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 the 84 residents who resided in the facility. This placed all residents at risk for unidentified and ongoing care issues.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents. Based on record review and interview, the facility failed to ensure the nurse aides received the required number of in-service training hours per year. This placed the residents at risk for impaired care.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents. Based on observation, interview, and record review, the facility failed to use appropriate barriers while sorting soiled resident laundry and to implement 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) for Residents (R) 35 and R49's wound care. The deficient practice placed the residents who reside in the facility at risk of infectious disease processes.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility staff failed to treat Resident (R) 70 (who required assistance with eating) with dignity when staff served R52 and R53, who sat at the same dining room table, their meals without serving R70. This placed the resident at risk for an undignified experience.

Inspectors wroteThe facility identified a census of 84 residents. The sample included 27 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 28 was free from psychotropic (a class of medications that alters mood or thought) medication without a gradual dose reduction (GDR - tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). The facility failed to ensure the physician provided the risk versus benefit for the continued use of buspirone (anti-anxiety) medication. This deficient practice placed R28 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification for Residents (R) 12 and R20, and the State Ombudsman Agency notifications of R12. This placed the residents at risk of being uninformed.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to revise the care plan to include Resident (R) 12's use of oxygen and R49's leg immobilizer. This placed the residents at risk for unmet care needs.

Inspectors wroteThe facility has a census of 84 residents. The sample included 27 residents, with five reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent skin breakdown for one resident, Resident (R) 49, who developed two open areas from a leg immobilizer (a brace or support device designed to restrict knee movement and keep the leg straight. This placed the resident at risk for further breakdown.- The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure). The Quarterly/Five Day Medicare Minimum Data Set (MDS). dated 04/21/25, documented R49 had intact cognition. [...]

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents, with one reviewed for foot care. Based on observation, record review, and interview, the facility failed to provide foot care to one resident, Resident (R) 49, whose toenails were long and over the top of her toes. This placed the resident at risk for complications, poor hygiene, discomfort, and injuries.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents, with nine reviewed for nutrition and weight loss. Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent weight loss for Residents (R) 20. This deficient practice resulted in significant weight loss and placed the resident at risk for further weight loss or health issues.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to store oxygen cannula, nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs), and a continuous positive airway pressure (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) equipment in sanitary conditions for Resident (R) 12, which placed the resident at risk of respiratory infections.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents, with one reviewed for competent staffing. Based on observation, record review, and interview, the facility failed to ensure staff possessed the appropriate skills and knowledge to monitor and communicate nursing orders, while waiting for direction from the physician, for one resident, Resident (R) 49, who sustained two open areas from an immobilizer. This placed the resident at risk for further breakdown.- The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure). [...]

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents, of whom one was reviewed for the provision of mental-related social services. Based on observation, record review, and interview, the facility failed to provide adequate medical social services to meet Resident (R) 37's medical health needs. This placed the resident at risk for decreased quality of care and life.

Inspectors wroteThe facility identified a census of 84 residents. The sample included 27 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's consultant pharmacist failed to recommend to the physician or the facility's Director of Nursing (DON) a gradual dose reduction (GDR -tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident (R) 28's psychotropic (a class of medications that alters mood or thought) medication. The facility failed to ensure the physician provided the risk versus benefit for the continued use of buspirone (anti-anxiety) medication. This deficient practice placed R28 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for one resident, Resident (R) 49. This placed the resident at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 36 residents. Based on observation, interview, and record review, the facility failed to store biologicals as required when staff failed to discard or destroy expired medications and failed to label Resident (R) 12 and R48 insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when the pens expired. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 84 residents. The sample included 27 residents, of whom one was reviewed for the provision of mental-related social services. Based on observation, record review, and interview, the facility failed to provide dental services to meet Resident (R) 37's, when she reported missing and loose teeth in her dentures. This placed the resident at risk for decreased quality of care and life.

Inspectors wroteThe facility identified a census of 90 residents with three residents reviewed for activities of daily living (ADL). Based on observation, record review and interview, the facility failed to provide care per the resident's preferences and to promote dignity for Resident (R) 1, who required extensive staff assistance for dressing and hygiene which resulted in R1 exposed her breast in the dining room. This deficient practice placed R1 at risk for impaired dignity.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to provide the services of a full time certified dietary manager for the 77 residents who resided in the facility and received their meals from the kitchen.

Inspectors wroteThe facility had a census of 77 residents. Based on observation, record review, and interview, the facility failed to serve palatable food during meals that maintained appetizing temperatures and conserved nutritive values for the residents who resided in the facility and received food from the facility kitchen. This placed the residents at risk for decreased enjoyment of meals and increased risk for weight loss.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents. Based on record review and interview, the facility failed to complete comprehensive Minimum Data Set Assessment (MDS) for one sampled resident, Resident (R)31 and eight unsampled residents, R13, R17, R26, R30, R36, R39, R58, and R64. This placed the resident's at risk for unmet care needs and inaccurate assessments.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents. Based on record review and interview, the facility failed to conduct a quarterly Minimum Data Set (MDS) assessment in the required timeframe for five sampled residents: Resident (R)3, R10, R54, R65, and R180 and 16 unsampled residents: Resident (R)5, R7, R18, R19, R22, R23, R37, R38, R40, R41, R48, R57, R58, R60, R66, and R67. This placed the residents at risk for unmet care needs and inaccurate assessments.

Inspectors wrote- The Medical Diagnosis section of R3's Electronic Medical Record (EMR) included diagnoses of congested heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic respiratory failure with hypoxia (inadequate supply of oxygen), urinary tract infection (UTI-an infection in any part of the urinary system), chronic kidney disease, retention of urine, and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Comprehensive Minimum Data Set (MDS), dated [DATE], documented R3 had moderately impaired cognition, was dependent on staff for oral hygiene, toileting hygiene, and dressing. R3 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was always incontinent of bowel. [...]

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive plan of care for Resident (R) 14 who was prescribed an anticoagulant (a group of medication that decreases blood ability to clot) which placed the resident at risk for uncommunicated care needs.

Inspectors wroteThe facility had a census of 77 residents. The sampled included 19 residents, with five reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interview, the facility failed to revise the care plan with person-centered interventions for dementia related behaviors for two sampled residents, Resident (R) 34 and R180. This placed the resident's at risk for abuse and decreased quality of life.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents, with six reviewed for bowel/bladder incontinence, indwelling catheter (tube placed in the bladder to drain urine into a collection bad), and urinary tract infections (UTI). Based on observation, record review, and interview, the facility failed to provide Resident (R) 28, R180, and R3 with appropriate catheter care which placed the residents at risk for infection.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents, with five reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for Resident (R) 34 and R180, who had dementia and behaviors, and failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial wellbeing for R180. This placed the residents at risk for abuse and decreased quality of life.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents, with six reviewed for unnecessary medications. Based on observations, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a 14-day stop date for Resident (R)12's as needed (PRN) lorazepam (Ativan-medication used to treat anxiety) and failed to identify and report the lack an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the use of an antipsychotic for R6 and R65. This placed the affected residents at risk for unintended affects related to psychotropic (affects mind or thoughts) drug medications.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents, with six reviewed for unnecessary medications. Based on observations, interview, and record review, the facility failed to ensure a 14-day stop date for Resident (R)12's as needed (PRN) lorazepam (Ativan-medication used to treat anxiety). The facility further failed to ensure R6 and R65 had an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the use of an antipsychotic. This placed the affected residents at risk for unintended affects related to psychotropic (affects mind or thoughts) drug medications.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to prevent a significant medication error for Resident (R) 34, whose Zyprexa (an antipsychotic medication) was not given for two days. The facility further failed to prevent medication errors when staff crushed three medications for R52 that were supposed to be given whole. This placed the residents at risk for decreased well-being and ineffective medication regimen.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)53's outdated insulin (hormone which allows cells throughout the body to uptake glucose) flex pen. This deficient practice placed the affected resident at risk for ineffective medications.

Inspectors wroteThe facility had a census of 77 residents. The sample included 19 residents, with six reviewed for indwelling catheter (tube placed in the bladder to drain urine into a collection bad), and urinary tract infections (UTI). Based on observation, record review, and interview, the facility failed to use acceptable infection control practices related to caring for indwelling catheters for three residents. This placed the residents at increased risk for infectious disease.

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserve nutritive value, flavor, and appearance for eight residents who received pureed diets placing the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff left uncovered, unattended clean laundry in a container in the hall, provided poor hand hygiene during cares, carried a trash bag from another hall onto the 500 hall, which contained positive COVID-19 (highly contagious, potentially fatal respiratory infection) residents without placing full personal protective equipment (PPE) prior to entering. [...]

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents of which one reviewed for dignity. Based on observation, record review, and interview, the facility failed to treat Resident (R) 24 with dignity promoting her quality of life by not cleaning R24's soft neck collar which contained food particles from meals. This placed R24 at risk for impaired dignity and decreased psychosocial wellbeing.

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents. with two residents reviewed for hydration, Resident (R) 3 and R16, who were on a fluid restriction (the amount of fluid required each day). The facility failed to review or revise the care plan for concise direction for staff regarding the fluid restriction. This placed the residents at risk for inadequate care. Findings Included: - R3's Electronic Medical Record (EMR) documented she had diagnoses of chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and edema (excess fluid tramped in the body's tissues). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. [...]

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents. Based on record review and interview, the facility failed to develop a discharge summary for one of two residents reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge plan for Resident (R) 71. This placed the resident at risk for receiving inadequate care.

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents with seven reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services and offer alternative bathing interventions for two sampled residents, Resident (R) 16, and R66. This placed the residents at risk for complications related to poor hygiene.

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents, with one reviewed for activities. Based on observation, record review, and interview, the facility failed to provide activities for one resident, Resident (R) 66, who had dementia, placing the resident at risk for decreased social interaction and boredom.

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents. with two residents reviewed for hydration, Resident (R) 3 and R16, who were on a fluid restriction (the amount of fluid required each day). The facility failed to monitor adequate hydration for R3 and R6. This placed the resident at risk for fluid overload or dehydration. Findings Included: - R3's Electronic Medical Record (EMR) documented she had diagnoses of chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and edema (excess fluid tramped in the body's tissues). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. [...]

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 55's bowel movements which placed the resident at risk for complications related to constipation (difficulty passing stools).

Inspectors wroteThe facility had a census of 76 residents. The facility identified six medications rooms. Based on observation, record review , and interview the facility failed to label two insulin (medication used to regulate the level of sugar (glucose) in the blood) kwik pens (a device used to inject insulin) with the date opened in one of three medication rooms. This placed the residents at risk for ineffective medication.