HAYSVILLE, KS - Federal inspectors identified multiple medication security breaches and patient care deficiencies at Diversicare of Haysville during a March 12, 2025 complaint investigation, including unsecured medication carts containing controlled substances and failures to properly monitor residents with complex medical conditions.
Serious Medication Security Violations
The most concerning findings involved medication cart security breaches throughout the facility. Inspectors documented three separate incidents where medication carts containing controlled substances were left unlocked and unattended in hallways and resident rooms. On March 10, surveyors found a cart on the 300 hallway containing five unopened insulin pens with no dating labels, plus scheduled medications and narcotics - all accessible with keys left in the locks.
"The medication cart should never be left unlocked and unattended," a Certified Medication Aide told inspectors. "The keys should never be left in the lock on the medication cart and left unattended."
These security lapses represent serious violations of federal regulations requiring controlled substances to be stored in locked compartments. Unsecured medications create risks for drug diversion, medication errors, and potential harm to residents who might access inappropriate medications.
Critical Medication Monitoring Failures
Inspectors identified dangerous gaps in medication monitoring protocols affecting residents with heart conditions and respiratory diseases. One resident receiving digoxin for heart rhythm disorders had no pulse monitoring documented before medication administration from October 2024 through March 2025 - despite physician orders requiring this safety check.
Digoxin monitoring is essential because the medication can cause life-threatening heart rhythm problems if administered when a patient's pulse is too low. Similarly, staff failed to monitor blood pressure readings before giving metoprolol, a medication that can dangerously lower blood pressure.
Another resident with chronic obstructive pulmonary disease required oxygen saturation monitoring above 90 percent, but staff failed to document these vital readings on 34 consecutive occasions across February and March 2025. This monitoring is crucial for residents with respiratory conditions, as oxygen levels below 90 percent indicate potentially dangerous breathing problems requiring immediate intervention.
Inadequate Dementia Care Documentation
The facility failed to provide appropriate dementia care services for a resident with severe cognitive impairment who frequently refused personal care. Documentation showed the resident received only 10 baths over a 70-day period, with nine documented refusals but no evidence of alternative care strategies or interventions.
Progress notes revealed episodes where the resident became agitated during care attempts, including throwing objects and becoming non-redirectable for hours. However, the resident's care plan lacked specific interventions for managing dementia-related behaviors or addressing care refusals.
Industry standards for dementia care require individualized approaches that recognize behavioral symptoms as expressions of unmet needs. Effective dementia care plans should include specific interventions, alternative approaches when residents refuse care, and strategies for reducing agitation.
Infection Control and Safety Violations
Inspectors documented multiple infection control failures that could spread diseases among vulnerable residents. These included oxygen tubing stored unsanitarily wrapped around wheelchair handles, mechanical lifts not cleaned between residents, and catheter tubing lying directly on floors.
A laundry cart containing clean linens was observed moving through resident hallways without protective covering, potentially contaminating clean supplies. Staff acknowledged these violations, with one nurse stating that "all shared equipment should be sanitized between residents" and oxygen equipment should be stored in clean plastic bags.
Staffing Reporting Inaccuracies
The facility failed to accurately report weekend staffing hours to federal regulators through the Payroll Based Journaling system. While the facility's resident council reported frequent weekend call-offs requiring manager coverage, these additional hours were not included in official staffing reports to Medicare and Medicaid.
Accurate staffing data is essential for regulatory oversight and ensuring facilities maintain adequate care levels. Underreporting staffing can mask potential care quality issues and prevent appropriate regulatory response.
Pharmacy Oversight Deficiencies
The facility's consultant pharmacist failed to identify several medication safety issues during required monthly reviews. These included missing dosage instructions for topical pain medications and failure to flag when physician orders lacked necessary monitoring parameters.
Federal regulations require consultant pharmacists to conduct comprehensive medication reviews and report irregularities to physicians. When pharmacists miss these safety issues, residents face increased risks of medication errors and adverse drug reactions.
Additional Issues Identified
Inspectors also documented vaccination policy violations, including failure to offer required pneumonia vaccines to eligible residents and missing documentation for vaccine consents and medical contraindications.
The investigation revealed systemic problems across multiple areas of care, from medication management to infection control, suggesting broader quality assurance issues requiring comprehensive facility-wide corrections.
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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