Stanton County Health Care: Medication Monitoring Failures - KS
The resident, identified in inspection records only as R11, is a woman with dementia, atrial fibrillation, and congestive heart failure. She was prescribed digoxin, a drug used to regulate heart rhythm, at a dose that had been adjusted upward in May 2025. Digoxin has a narrow margin between a therapeutic dose and a toxic one. A pulse check before each dose is standard practice because the drug can slow the heart dangerously if the rate is already too low.
Nobody checked.
Not once in May, when nurses had 31 opportunities. Not once in June, when they had 30. Not once in July, with 31 more chances. And not once across the 27 doses documented through late August, when inspectors arrived.
Her blood pressure was also not checked before administration of her carvedilol, a beta-blocker prescribed alongside the digoxin, on any of the 31 days in May that the medication was given. Carvedilol slows the heart and lowers blood pressure; the same logic applies.
The care plan the facility maintained for R11 directed staff to give medications as directed. It said nothing specific about digoxin or carvedilol. There were no instructions about pulse thresholds, no guidance on what reading should prompt a nurse to hold the dose, no documentation that the monitoring requirement had ever been considered.
The facility held monthly pharmacy and therapeutics meetings, according to Administrative Nurse D, who spoke with inspectors on August 26. The pharmacist and physician both attended. The pharmacist conducted monthly medication record reviews.
The pharmacist's reviews for R11 contained no recommendation that her pulse be monitored before digoxin administration.
That means the gap ran through every layer of oversight the facility had built. Bedside nurses didn't check. The care plan didn't require it. The pharmacist didn't flag it. The monthly meetings with the physician present produced nothing.
R11's dementia had been progressing slowly, according to her records. When she became agitated or restless, staff were directed to redirect her attention. Her psychotropic drug assessment, completed just days before inspectors arrived, noted those episodes and the redirection strategy. Her cardiac medications appeared nowhere in that document's monitoring framework.
The May 2025 digoxin order was itself a replacement for an earlier one. An order from January 2024 had prescribed digoxin 125 micrograms daily for atrial fibrillation. That order was discontinued on May 1, 2025, the same day a new order was entered. The new order specified digoxin 125 microgram tablets, but directed staff to administer 0.625 milligrams daily, a fivefold increase in dose. The shift made consistent pre-dose monitoring more important, not less.
Inspectors classified the violation under F0756, which covers the pharmacist's role in medication management, and rated it at the level of minimal harm or potential for actual harm. The affected population was listed as some residents, suggesting R11 was not the only person whose medication monitoring was reviewed.
What the records don't show is any point at which anyone paused and asked whether a woman with a failing heart, on a drug that requires careful titration, was being watched closely enough. The monthly meetings happened. The pharmacist reviewed. The care plan was revised as recently as April. None of it caught four months of missed pulse checks on a resident whose heart was the reason she was on the drug in the first place.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stanton County Health Care Facility Ltcu from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
STANTON COUNTY HEALTH CARE FACILITY LTCU in JOHNSON, KS was cited for violations during a health inspection on August 28, 2025.
The resident, identified in inspection records only as R11, is a woman with dementia, atrial fibrillation, and congestive heart failure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.