HAYSVILLE, KS - Federal inspectors found serious medication management problems and inadequate dementia care at Diversicare of Haysville during a March 12, 2025 inspection, citing the facility for leaving medication carts unlocked and failing to properly monitor residents receiving critical medications.
Critical Medication Safety Breaches Documented
Inspectors discovered multiple instances of unlocked medication carts containing controlled substances, including narcotics, left unattended throughout the facility. During the initial tour on March 10, investigators found an unlocked cart on the 300 hallway containing five opened, undated insulin pens. Later that morning, another cart was discovered unlocked with both medication and narcotic keys still in the locks.
The violations represent a fundamental breakdown in medication security protocols. When medication carts are left unsecured, residents face significant risks from potential medication theft, tampering, or accidental ingestion by confused residents. Controlled substances require particular vigilance due to their potential for abuse and the serious health consequences of misuse.
"The medication cart should never be left unlocked and unattended," stated Certified Medication Aide R during the inspection. "The keys should never be left in the lock on the medication cart and left unattended."
Licensed Nurse G acknowledged the problem, confirming that medication carts should remain locked when staff walk away from them and that narcotic medications should be counted and verified by two nurses at each shift change.
Oxygen Monitoring Failures Create Medical Risks
The inspection revealed that staff failed to monitor and document oxygen saturation levels for a resident with chronic obstructive pulmonary disease (COPD), despite physician orders requiring such monitoring. Resident 14, who has multiple conditions including heart failure and diabetes, had physician orders to maintain oxygen saturation above 90 percent, but staff documented this vital measurement on zero occasions over a 34-day period in February and March 2025.
Oxygen saturation monitoring is essential for residents with COPD because it indicates how well the lungs are functioning and whether the body is receiving adequate oxygen. When levels drop below 90 percent, residents may require supplemental oxygen or other interventions to prevent complications including organ damage, confusion, and potentially life-threatening respiratory failure.
The facility's administrative nurse admitted that the physician's order had not been correctly entered into the electronic medical record system to include a space for documenting the oxygen readings. This systematic failure meant that staff were signing off on completing the monitoring without actually performing or recording the measurements.
Inadequate Dementia Care and Personal Hygiene
Inspectors found that a resident with severe cognitive impairment received inadequate dementia-specific care and experienced poor personal hygiene maintenance. Resident 12, who has dementia and requires assistance with daily activities, received bathing only 10 times over a 70-day period, with nine documented refusals that lacked appropriate intervention strategies.
Dementia care requires specialized approaches when residents refuse personal care. Effective dementia care involves understanding individual triggers, using redirection techniques, and offering alternatives rather than simply documenting refusals. Residents with dementia may refuse care due to confusion, fear, or discomfort, but skilled staff can often find alternative approaches that maintain dignity while ensuring necessary care.
During the inspection, the resident was observed with greasy, uncombed hair and could not recall when she last received bathing assistance. Progress notes revealed instances where staff were unable to redirect the resident during agitated episodes, including times when she threw objects and feces at staff.
Licensed Nurse G noted that "staff should offer alternative care if she did not want bathing or showers" and that "offering R12 a snack was often effective" for redirection. However, the resident's care plan lacked specific interventions for managing her dementia-related behaviors and refusals.
Heart Medication Monitoring Gaps Identified
The facility failed to monitor vital signs before administering potentially dangerous heart medications to another resident. Resident 54, who takes digoxin for irregular heartbeat and metoprolol for high blood pressure, did not receive required pulse and blood pressure monitoring before medication administration over a six-month period.
Digoxin is a medication that can cause dangerous heart rhythm problems if administered when a patient's pulse is too low. Similarly, metoprolol can cause blood pressure to drop to dangerous levels, particularly when combined with other medications. Standard medical practice requires checking these vital signs before each dose to ensure safe administration.
The resident's physician orders lacked specific parameters for when to hold these medications, such as "do not give if pulse below 60" or "hold if blood pressure below 100/60." This absence of safety parameters, combined with the lack of monitoring, created multiple opportunities for adverse effects.
Administrative Nurse D acknowledged that "a pulse should be obtained prior to administration of digoxin as well as a blood pressure for metoprolol," confirming that established protocols were not being followed.
Infection Control Violations Compromise Safety
Multiple infection control failures were documented throughout the facility, creating risks for disease transmission among vulnerable residents. Inspectors observed a Foley catheter drainage bag lying directly on the floor, oxygen tubing stored improperly, and shared mechanical lift equipment not sanitized between residents.
Proper infection control is particularly critical in nursing homes because residents often have compromised immune systems and are at higher risk for serious complications from infections. Urinary catheters must be positioned to prevent bacteria from entering the urinary system, while shared equipment can spread dangerous pathogens between residents if not properly cleaned.
The facility's own infection control policy emphasized maintaining "a safe, sanitary and comfortable environment" to prevent disease transmission, but staff practices did not align with these stated standards.
Medical Context and Industry Standards
These violations reflect broader challenges in nursing home medication management and specialized care delivery. Federal regulations require nursing homes to maintain comprehensive medication management systems that prevent errors and ensure appropriate monitoring of high-risk medications.
Dementia care standards emphasize person-centered approaches that accommodate individual preferences and behavioral patterns while maintaining essential health and hygiene needs. Research shows that individualized intervention strategies can significantly reduce care refusals and improve quality of life for residents with cognitive impairments.
Oxygen saturation monitoring represents a basic safety measure for residents with respiratory conditions. The normal range for healthy individuals is 95-100 percent, while levels below 90 percent indicate significant breathing problems requiring immediate medical attention.
Additional Issues Identified
The inspection also revealed problems with pharmaceutical oversight, including a consultant pharmacist who failed to identify medication monitoring gaps and incomplete physician responses to medication recommendations. The facility reported inaccurate staffing data to federal regulators, potentially masking weekend staffing shortages that could impact resident care quality.
Vaccination protocols were not properly implemented, with residents missing required pneumonia vaccines despite giving consent for immunization.
The March 2025 inspection covered multiple areas of resident care and safety, reflecting ongoing regulatory oversight of nursing home operations to protect vulnerable residents who depend on professional care for their daily needs and medical management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diversicare of Haysville from 2025-03-12 including all violations, facility responses, and corrective action plans.
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