Halstead Health And Rehabilitation Center
HALSTEAD HEALTH AND REHABILITATION CENTER in HALSTEAD, KS — inspection on April 15, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
bed-hold policies.
minimal harm Based on interviews and record reviews, the facility failed to provide written notification to the Office of the Long-Term Care Ombudsman (LTCO) regarding six residents transferred from the facility, five
admission/discharge report from 02/14/26 to 04/14/26 indicated one resident transferred to another facility and five residents transferred home. On 04/14/26 at 10:25 AM an interview with Social Service X revealed the only time she notifies the LTCO is when a resident is transferred to the hospital.
She has not notified the LTCO with residents transferring to home or another facility. On 04/15/26 at 11:15 AM, an interview with Administrative Staff A revealed she expected any transfers from the facility to be sent to the ombudsman.
The facility did not provide a policy regarding notification of the ombudsman on transfers to another facility or to home upon request.
175446 04/15/2026
Halstead Health and Rehabilitation Center 915 McNair Street Halstead, KS 67056
Findings included:- R13's Electronic Medical Record (EMR) documented
osteomyelitis (local or generalized infection of the bone and bone marrow), and intervertebral disc disorder (occurs when the discs between vertebrae are damaged or degenerate, leading to compression or irritation of nearby nerve roots.) with radiculopathy (pain, tingling, or weakness radiates along the affected nerve, often down the legs). R13's 03/24/26 Quarterly Minimum Data Set (MDS) documented a BIMS of 15.
The MDS noted R13 required supervision for walking 10 feet and required partial assistance for walking 50 feet.
The MDS incorrectly documented R13 had no falls since the previous MDS assessment. R13's Care Plan, dated 01/16/25, documented R13 continued to do things independently even when he had been educated several times to use his call light. R13's 01/16/26 General Note, under progress notes at 01:59 AM, documented staff went into R13's room because his call light was on and found him lying next to his heater on top of some boxes, papers, and his bed side table. R13 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. R13 reported tenderness when putting weight on his leg.
The nurse encouraged R13 to go to the emergency room, but R13 refused.
The provider was notified and gave an order for a hip x-ray and pain medication. R13's 01/16/26 Lab/Diagnostic Note, under progress notes at 08:33 AM, documented mobile X-ray came to the facility to x-ray R13's leg.
The facility received the report of a nondisplaced fracture of the left superior pubic ramus, and the doctor was notified.
She states that she will be at the facility within the hour and she will assess the resident. R13's 01/16/26 Lab/Diagnostic Note, under progress notes at 10:41 AM, documented the provider arrived to see R13. R13 refused a follow up CT and refused an orthopedic consultation.
R13 stated if he decided that he needed additional assistance then he would consider therapy.
The provider also explained R13 would not be a good surgical candidate. On 04/13/26 at 10:20 AM, R13 had been working on walking in the hall with therapy.
Therapy assisted R13 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. On 04/15/26 at 8:46 AM, Administrative Nurse E stated she coded part of the MDS, but the regional nurse completed some of the coding which included the falls portion of the MDS.
Administrative Nurse E agreed that R13 had a fall the resulted in a hip fracture and it should have been coded as a fall with major injury.
Administrative Nurse E stated she would message the regional nurse and find out why she coded it like that. On 04/15/26 at 10:05 AM, Administrative Nurse E stated the regional nurse stated she coded it in error, and the regional nurse would complete a correction immediately. On 04/15/26 at 10:57 AM, Administrative Nurse D reported she expected the MDS to be completed accurately to accurately reflect the resident.
The undated MDS policy documented the facility will conduct a comprehensive MDS assessment according to the Federal regulations and Medicare guidelines.
The facility staff will follow the current Resident Assessment Instrument (RAI - a comprehensive, standardized tool used in long-term care facilities to assess residents, guide care planning, and monitor quality of care) manual for proper procedures on completing the MDS.
175446 04/15/2026
Halstead Health and Rehabilitation Center 915 McNair Street Halstead, KS 67056
During an observation on 04/14/26 at 07:42 AM, R3 attempted to go to the door to go out to smoke.
Licensed Nurse (LN) HH stood in front of R3 and told him it was one and a half hours until the next smoking break. R3 got frustrated and told LN HH to turn him around in his wheelchair, then LN HH turned him around in the wheelchair and assisted him to the dining room. R3's sock was half off his foot and dragged the floor.
R3 held his foot off the floor.
During an interview on 04/14/26 at 07:48 AM, LN I stated she thought she should not have assisted R3 in the wheelchair without foot pedals on but was not sure. LN I then asked Certified Medication Aide (CMA) S if R3 required foot pedals when staff are pushing him in his wheelchair. CMA S stated R3 used the foot pedals when he was assisted in his wheelchair. If he is self-propelling, he does not need them.
During an interview on 04/15/26 at 08:46 AM, Administrative Nurse E confirmed staff should not assist R3 in the wheelchair without foot pedals.
During an interview on 04/15/26 at 10:57 AM, Administrative Nurse D stated that staff should use foot pedals when they are assisting residents in the wheelchair.
The facility's undated Falls policy documented the residents would be assessed for risks of falls and interventions would be implemented to reduce risk of falls.
175446 04/15/2026
Halstead Health and Rehabilitation Center 915 McNair Street Halstead, KS 67056
Findings included: - R6's Electronic Medical Record (EMR) from the Diagnosis tab documented Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), chronic kidney disease-stage three (CKD), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), obstructive uropathy (a structural or functional blockage in the urinary tract that prevents urine from flowing freely, causing it to back up and damage the kidneys), and retention of urine (the inability to fully or partially empty the bladder). R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of four, which indicated severely impaired cognition.
The MDS documented R6 had an indwelling catheter during the observation period.
The Urinary Incontinence Care Area Assessment (CAA), dated 12/09/25, documented a diagnosis of Alzheimer's, obstructive and reflux uropathy, retention of urine, and BPH.
R6's Care Plan, dated 08/25/23, documented an order from R6's urologist which directed staff not to remove R6's catheter. On 02/17/25, the plan directed staff were to apply Skin-prep (liquid skin barrier) prior to attaching the Stat-lock (adhesive medical tubing stabilization device) for the suprapubic catheter.
During an observation on 04/14/26 at 12:37 PM, Licensed Nurse H assessed and cleaned the suprapubic catheter site on R6's abdomen.
The Stat-lock was attached to R6's left upper thigh and was confirmed by Licensed Nurse H.
During an observation on 04/15/26 at 9:22 AM, Licensed Nurse I assessed and cleaned the suprapubic catheter site on resident R6's abdomen, then attached a Stat-lock to R6's left upper thigh, securing the tubing from R6's abdomen.
During an interview on 04/14/26 at 2:32 PM, Licensed Nurse H stated they were unaware of a Stat-lock being adhered to the abdomen and would ask the Administrative Nurse D for directions on where to place the Stat-lock for a suprapubic catheter. On 04/14/26 at 02:34 PM, Administrative Nurse D stated she would expect the Stat-lock to be anchored to the leg.
During an interview on 04/14/26 at 02:43 PM, Administrative Nurse D stated the facility catheter policy does not state where to place a Stat-lock for a suprapubic catheter, however, the suprapubic catheter replacement competency states the tubing should be anchored to the abdomen.
Administrative Nurse D stated they were unaware the competency checklist required the tubing to be anchored to the abdomen the previous times they reviewed the checklist.
The facility competency checklist states the catheter tubing should be secured to the abdomen.
175446 04/15/2026
Halstead Health and Rehabilitation Center 915 McNair Street Halstead, KS 67056
for R27 to have house shakes TID was changed to one time a day by the facility.
She said she would
Administrative Nurse E stated the 168 lb. weight should have been reported immediately to the nurse
was to review the previous weight and perform a re-weight if there was a significant change.
Administrative Nurse E then stated on 01/15/26 R27 had a task ordered for weekly weights.
The facility policy Weight Loss Prevention, dated 04/20/20, documented that residents with poor or declining nutritional intake, weight loss, BMI <22 and/or pressure ulcers would have nutritional interventions added as needed and the Registered Dietitian should be consulted.
175446 04/15/2026
Halstead Health and Rehabilitation Center 915 McNair Street Halstead, KS 67056
stops beating) qualified in the facility and confirmed R2's emergency tracheostomy supplies and
with a tracheostomy had an emergency kit and equipment at the bedside because hospice provided
competency was performed annually for the nursing staff.
Administrative Nurse D also stated there was not an available emergency kit or Ambu bag at bedside because staff were told by the physician not to reinsert the tracheostomy if it came out, staff were to immediately call 911. On [DATE] at 08:04 AM, Administrative Nurse D said the Ambu bag was directly outside R2's room on the crash cart, not at the bedside.
She verified that if staff needed the Ambu bag because R2 was in respiratory distress, staff would have to move the Hoyer lift, uncover the cart, and wheel it into the room.
The facility policy Respiratory Care, dated [DATE], documented the facility provided necessary respiratory care and services in accordance with professional standards of practice, the resident's care plan, and the resident's choice.
175446 04/15/2026
Halstead Health and Rehabilitation Center 915 McNair Street Halstead, KS 67056
Findings included:- Observed on 04/13/26 at 08:00 AM, the posted
sheet lacked the total hours worked and did not list the facility name.
Review of the daily staffing sheets from 05/13/25 and 03/18/26 revealed the posted staffing sheets lacked the total hours worked.
During an interview on 04/14/26 at 11:48, Administrative Nurse D stated the nightshift nurse filled out the next day staffing sheet and then posted it for display before the start of the next shift.
Administrative Nurse D also said the listed column that was labeled actual hours were the total hours worked.
The facility policy Daily Nurse Staff Posting, dated 11/28/17, documented at the beginning of each shift the charge nurse would compute the number of full-time equivalents on duty and record the number on the Daily Nurse Staffing form.
The form would then be posted in designated locations in such a manner that it could be easily seen and read.
The policy also documented the facility census would be recorded on the form and be updated with any admissions or discharges throughout the day.
During an interview on 4/15/26 at 11:28 AM, Administrative Staff A revealed they do not have an answer for the temperatures on the temperature log but stated that it sounded like the facility needed to have some education and initiate a performance improvement plan for staff regarding this topic.
The facility's 04/06/20 Food Storage policy documented staff are to label all food items with the name of the food and the date it was opened or when it should be used by, and food which has passed the expiration date should be discarded.
The facility did not provide a hand hygiene policy for dietary staff.
175446 04/15/2026
Halstead Health and Rehabilitation Center 915 McNair Street Halstead, KS 67056
Findings included:- An observation of tracheostomy care for Resident (R) 2 on 04/14/26 at 07:50 AM, revealed Licensed Nurse (LN) H performed hand hygiene, donned gloves, and wore a mask, LN H did not don a gown prior to providing cares and changing gloves before placing clean four by four gauze or the tracheostomy cannula (a tube to maintain a patient's airway for breathing). An observation on 04/14/26 at 11:35 AM, during the delivery of resident's personal items, revealed Housekeeping/Laundry Staff U placed the covered cart in hall 100, then took the items off the cart and carried the items over her shoulder to hall 200 without the cart, uncovered.
During an observation on 04/14/26 at 12:37 PM, prior to doing wound care for R6, LN H performed hand hygiene and applied a gown and gloves. LN H then did the wound care and upon leaving the room after providing the wound care LN H reached down while holding the gauze and wound cleanser inspected and manipulated the suprapubic catheter (a tube inserted through the abdominal wall into the bladder to drain urine) tubing then left the room without performing hand hygiene. On 04/15/26 at 10:19 AM, LN I revealed wound care supplies should be kept in the residents' room or bagged and taken to the wound nurse and hand sanitizing should be performed before/after wound care and if soiled. On 04/16/26 at 08:00 AM, an interview with LN H revealed she should have changed gloves and wore a gown prior to tracheostomy care. On 04/15/26 at 08:04 AM, an interview with Administrative Staff D revealed she expected the staff to wear a gown, gloves, and a mask at minimum for EBP, and hand sanitizing should be completed after the dirty side is done and new gloves applied. On 04/16/26 at 10:10 AM, an interview with Administrative Staff D revealed she expected staff to follow the hand hygiene and glove use during catheter care and if touching a bag or catheter tubing, staff should perform hand hygiene. On 04/16/26 at 10:17 AM, an interview with Housekeeping Staff V revealed she expected the laundry staff to place the covered cart next to the room where they would deliver personal items to the residents and make sure the cart is covered between rooms.
The facility's policy Enhanced Barrier Precautions (EBP) dated 04/1/24 Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs target gown and glove use during high contact resident care activities.
The facility's policy Hand Hygiene, dated 11/28/17, documented staff are to wash hands with soap and water when hands are visibly soiled, cleanse hands with alcohol-based hand rub before and after contact with the resident, after contact with blood, body fluids or visibly contaminated surfaces or other objects, after removing personal protective equipment, before performing a procedure such as an invasive device urinary catheter and or dressing care.
175446 04/15/2026
Halstead Health and Rehabilitation Center 915 McNair Street Halstead, KS 67056