Stanton County Health Care: Missed Pulse Checks - KS
The resident, identified in inspection records only as R11, takes digoxin for atrial fibrillation. Digoxin works by slowing the heart rate, and giving it when a patient's pulse is already too slow can cause a dangerous cardiac event. R11 has a BIMS cognitive score of three, indicating severely impaired cognition. She cannot advocate for herself.
Inspectors reviewed four months of medication administration records and found the same gap every time. In May, staff skipped the pulse check on all 31 doses. In June, all 30. In July, all 31. Through August 27, another 27 doses without a single check. One hundred nineteen opportunities. Zero pulse readings recorded.
When inspectors asked Administrative Nurse D about it, she said the physician did not monitor the pulse or blood pressure of every resident on heart or blood pressure medications. She said residents received weekly vital signs, but not daily. Then she said she assumed the physician knew which medications required monitoring before administration, but added she could not be certain.
That answer — an assumption, and an uncertain one — was the facility's explanation for four months of missed checks on a cognitively impaired woman with a heart condition.
The facility had no policy on unnecessary medications, inspectors noted. R11's care plan, last revised in April, directed staff to give medications as ordered. It contained no instructions specific to her digoxin at all.
R11's records showed she had episodes of agitation and restlessness. Staff redirected her when she became upset. She needed substantial help bathing and moderate help with most daily tasks. She depended on the people around her entirely.
For four months, those people gave her a heart drug that requires a pulse check first, and nobody took one.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 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, takes digoxin for atrial fibrillation.
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.