Catholic Care Center: CPR Withheld From Full-Code Resident - KS
The inspection was a complaint investigation. Someone had reported what happened, and federal inspectors came to find out if it was true. It was.
The finding, documented under F0678, a tag that covers emergency care and cardiopulmonary resuscitation, cited the facility for failing to ensure that a resident who had explicitly chosen resuscitative measures actually received them. The resident is identified in inspection records only as R1. What happened to R1 in the moments that mattered most is not described in detail in the public record. What is documented is the conclusion inspectors reached: the facility's failure put R1 in immediate jeopardy, and because the same failure could happen to any of the other 61 residents who had made the same choice, all of them were in immediate jeopardy too.
Sixty-one people had signed paperwork saying they wanted to live. The facility's own records confirmed their wishes. And the staff, when the moment came for one of them, did not act on it.
On November 18, 2025, at 2:41 in the afternoon, Administrative Staff A, as the person is identified in inspection records, received a copy of the Immediate Jeopardy Template from inspectors. They were told directly: the facility's failure to ensure CPR was provided to R1 had placed R1 and all 61 full-code residents in immediate jeopardy. The IJ was formally in effect.
Immediate jeopardy is not a finding inspectors reach easily or often. It means the deficient practice has caused, or is likely to cause, serious injury, harm, impairment, or death. It means the situation requires immediate correction. It means that, in the judgment of federal regulators, the residents inside that building were not safe.
What the inspection report does not say is whether R1 survived.
The facility moved quickly once the IJ was in place. Nursing staff were re-educated on residents' rights, including the right to self-determination and the right to formulate advance directives. That is a striking phrase to need to teach: the right to self-determination. R1 had exercised that right. They had made their wishes known through the proper channels, in the proper forms, and had presumably trusted that the people caring for them understood what those forms meant.
All licensed nurses were required to demonstrate competency through a written quiz covering code status and Code Blue protocols, and through return demonstration, meaning they had to physically show they could perform what was being tested. Mock Code Drills were conducted two to four times per week. The Annual Education Calendar was updated to include Code Blue protocols and honoring code status. The facility added Code Blue response to the list of clinical competencies demonstrated upon hire.
That last item is worth pausing on. New employees at Catholic Care Center will now be required to demonstrate, on their first day of clinical work, that they know how to respond to a Code Blue and that they understand what it means to honor a resident's code status. That requirement did not exist before R1 did not receive CPR.
A subsequent onsite survey verified that the corrective actions had been completed. Inspectors downgraded the finding to past noncompliance, with a scope and severity of K, meaning a pattern of immediate jeopardy. The immediate jeopardy was lifted. The facility was no longer in the most dangerous category of federal violation.
But the classification of K, a pattern, is significant. Immediate jeopardy at the pattern level means inspectors determined this was not an isolated incident, not a single nurse who froze, not one bad moment in an otherwise functioning system. A pattern means the problem was more widespread than a single event. It means the failure to honor code status, to act when a resident with full-code designation needed CPR, was something that could happen again because it reflected something systemic about how the facility operated.
The gap at the center of this case is not a complicated one. Advance directives exist precisely because people cannot speak for themselves in a medical emergency. A full-code designation is the clearest possible instruction a resident can leave: if I stop breathing, if my heart stops, try to bring me back. It requires no interpretation. It requires no judgment call in the moment. It requires action.
Catholic Care Center is a nursing facility in Bel Aire, a small city in Sedgwick County, just outside Wichita. It operates under a name that carries an explicit promise of care. The residents who chose full-code status, all 61 of them, made a decision about their own lives and trusted the facility to carry it out.
One of them needed that promise kept. The staff did not keep it.
The corrective actions the facility completed, the re-education, the competency testing, the mock drills, the updated calendar, the new hire requirements, are all appropriate responses to the finding. They are what a facility is supposed to do when something like this happens. Whether they are enough depends on questions the inspection report cannot answer: why staff did not perform CPR on R1 in the first place, what they believed about R1's code status in that moment, whether they knew and failed to act or did not know and therefore did not act.
None of that is in the public record. What is in the public record is that a resident who wanted to be resuscitated was not, that federal inspectors determined this placed dozens of other residents in immediate jeopardy, and that the facility received a pattern-level immediate jeopardy citation, the most serious finding in the federal inspection system.
R1 had made their wishes known. That is the last thing the record tells us about them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Catholic Care Center, Inc from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 31, 2026 · Our methodology
CATHOLIC CARE CENTER, INC in BEL AIRE, KS was cited for violations during a health inspection on November 18, 2025.
The inspection was a complaint investigation.
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.