Halstead Health: Fall Data Hidden After Hip Fracture - KS
The resident, identified as R13 in inspection records, has hemiparesis and chronic bone infections. His care plan noted he "continued to do things independently even when he had been educated several times to use his call light."
On January 16, 2026, at 1:59 AM, staff found R13 lying next to his heater on top of boxes, papers, and his bedside table after his call light went on. He complained of back pain and left hip pain. R13 had swelling behind his left ear from hitting the heater and his left cheek was reddened.
The resident reported tenderness when putting weight on his leg. A nurse encouraged him to go to the emergency room, but R13 refused. The provider ordered a hip x-ray and pain medication.
Mobile X-ray came to the facility that morning. The report showed a nondisplaced fracture of the left superior pubic ramus. The doctor was notified and arrived within an hour to assess R13.
R13 refused a follow-up CT scan and refused an orthopedic consultation. He stated if he decided he needed additional assistance, he would consider therapy. The provider explained R13 would not be a good surgical candidate.
Despite this documented fall and resulting hip fracture, the facility's March 24, 2026 Quarterly Minimum Data Set assessment incorrectly stated R13 had no falls since the previous assessment. The MDS is a comprehensive federal assessment tool that determines Medicare reimbursement rates and quality ratings for nursing homes.
On April 13, 2026, R13 was working on walking in the hallway with therapy staff. When therapy assisted him back to his room, he sat in his wheelchair and reported he had falls and was working with therapy to get stronger after his last fall.
Administrative Nurse E told federal inspectors on April 15 that she coded part of the MDS, but a regional nurse completed the falls portion. The administrative nurse agreed that R13 had experienced a fall that resulted in a hip fracture and "it should have been coded as a fall with major injury."
She stated she would message the regional nurse to find out why the fall wasn't properly documented.
Later that morning, Administrative Nurse E reported the regional nurse admitted she "coded it in error" and would complete a correction immediately.
Administrative Nurse D told inspectors she expected the MDS to be completed accurately to reflect the resident's actual condition.
The facility's MDS policy states staff will conduct comprehensive assessments according to federal regulations and Medicare guidelines. Staff are required to follow the current Resident Assessment Instrument manual for proper MDS completion procedures.
The inspection found R13 required supervision for walking 10 feet and partial assistance for walking 50 feet. His cognitive assessment showed a score of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment.
R13's medical record documented diagnoses of hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The disc disorder occurs when discs between vertebrae are damaged, leading to compression of nearby nerve roots and causing pain, tingling, or weakness that radiates down the legs.
Federal inspectors determined the facility failed to accurately complete the required data set for the resident. The violation was classified as having minimal harm or potential for actual harm, affecting few residents.
The inaccurate MDS documentation means federal Medicare quality ratings and reimbursement calculations were based on incomplete information about resident safety incidents at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Halstead Health and Rehabilitation Center from 2026-04-15 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Halstead Health and Rehabilitation Center
- Browse all KS nursing home inspections
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: June 15, 2026 · Our methodology
HALSTEAD HEALTH AND REHABILITATION CENTER in HALSTEAD, KS was cited for violations during a health inspection on April 15, 2026.
The resident, identified as R13 in inspection records, has hemiparesis and chronic bone infections.
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.
Frequently Asked Questions
- What happened at HALSTEAD HEALTH AND REHABILITATION CENTER?
- The resident, identified as R13 in inspection records, has hemiparesis and chronic bone infections.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in HALSTEAD, KS, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from HALSTEAD HEALTH AND REHABILITATION CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 175446.
- Has this facility had violations before?
- To check HALSTEAD HEALTH AND REHABILITATION CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.