Stanton County Health Care Facility Ltcu

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

The facility’s “Antipsychotic Drug Use” dated 03/06/25, documented that antipsychotic drug therapy would be used only when it is necessary to treat a specific condition. Antipsychotic medication should not be used for sedation or convenience. Antipsychotics should be used if one or more of the following is/are the only indications: wandering, poor self-care, restlessness, impaired memory, anxiety, depression (without psychotic features), insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors which do not represent danger to the resident or others.

Event ID:

Facility ID:

17E445

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

17E445

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stanton County Health Care Facility Ltcu

404 N Chestnut Johnson, KS 67855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

(30) day advance notice of the transfer or discharge. A transfer or discharge notice would include the following: The reason for the transfer or discharge; the effective date of the transfer or discharge; The location to which the resident is transferred or discharged ; an explanation of the resident’s right to appeal the transfer or discharge to the State; and the name, address, and telephone number of the state long-term care ombudsman. The reason(s) for a transfer or discharge will be recorded in the resident’s clinical record. - Resident R20's Electronic Medical Record (EMR) included diagnoses of disorientation, urinary tract infection (UTIan infection in any part of the urinary system), diarrhea, diabetes mellitus(DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), heart failure, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident R20’s “Minimum Data Set” (MDS) dated [DATE REDACTED] recorded a discharge return anticipated.

On 08/11/25, the MDS recorded an entry into the facility.

The “Progress Note” dated 08/09/25 at 11:11 AM documented a telephone order received by

the provider to transfer Resident R20 to the hospital for admission related to sepsis from urinary tract infection.

The “Progress Note” dated 08/11/25 at 01:02 PM documented that Resident R20 was readmitted to

the long-term care unit, via wheelchair.

On 08/26/25 at 08:20 AM, Resident R20 sat in her wheelchair, dressed and groomed appropriately for the day.

On 08/27/25 at 11:00 AM, Administrative Nurse F reported for the transfer of a resident from the long-term care unit to the hospital. The nurse would call report to the hospital about the resident’s condition, send a face sheet, and a CCD (Continuity of Care Document). Administrative Nurse F stated the residents’ representative would be notified via phone or in person if at the facility at the time of discharge. No written form was given to the resident or the resident’s representative of the reason for the transfer.

The facility’s “Emergency transfer/discharge”, policy dated 01/22/25, documented should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, the facility will implement the following procedure of prepare the resident for transfer, a transfer form to be sent with the resident, notify the durable power of attorney or other family member, and other as appropriate or as necessary.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

17E445

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

17E445

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stanton County Health Care Facility Ltcu

404 N Chestnut Johnson, KS 67855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

halls with her walker before accepting assistance to go to bed. The progress notes further documented that five minutes later, the alarm activated, and Resident R3 was observed to be cleaning urine from the floor. Staff offered a shower, but she refused, became agitated, sat in her recliner, and verbally ordered staff to leave.

On 08/26/25 at 01:53 PM, Resident R3 sat in her wheelchair in her room, holding a bible in her hands. Resident R3 reported

she was reading. On 08/27/25 at 01:20 PM, Resident R3 sat at the activity room door, in her wheelchair. She greeted visitors pleasantly, and the activity staff invited Resident R3 in to participate.On 08/28/25 at 09:03 AM, Social Service X reported that the Licensed Master Social Worker (LMSW) was contracted, did not come to the facility, and reviewed the electronic charting. Social Service X reported she had not received guidance from the LMSW related to the behavioral aspects of the residents, and no mental health provider sees the resident

in person or via telehealth consultations. The facility's Social Services policy, dated 02/2024, documented that the director of social services is a qualified social worker and is responsible for the oversight of the social services manager, assessing residents' psychosocial needs. Emotional support and ensures regulatory compliance, and will consult with social services personnel.

Event ID:

Facility ID:

17E445

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

17E445

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stanton County Health Care Facility Ltcu

404 N Chestnut Johnson, KS 67855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Level of Harm - Minimal harm or potential for actual harm

The facility identified a census of 22 residents. The sample included 12 residents, with five residents reviewed for dementia care. Based on observation, record review, and interview, the facility failed to ensure staff provided the necessary person-centered activities and interventions to address Resident (R) 11's dementia (a progressive mental disorder characterized by failing memory, confusion) diagnosis. This deficient practice placed Resident R11 at risk of ineffective treatment and decreased quality of care.Findings included:- Resident R11's Electronic Medical Record (EMR) documented diagnoses of dementia with psychotic disturbance (a condition characterized by cognitive decline accompanied by psychotic symptoms such as hallucinations and delusions), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), delirium (sudden severe confusion, disorientation, and restlessness), congestive heart disease (CHF- a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heart beat).Resident R11's Annual Minimum Data Set (MDS) dated 08/08/25 documented she had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. Resident R11 required partial/moderate assistance from staff for most activities of daily living (ADL). Resident R11 required substantial staff assistance with bathing. Resident R11 received an antipsychotic and an antidepressant medication regularly.Resident R11's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/21/25 documented Resident R11 had a slow cognitive decline due to dementia.Resident R11's Psychotropic Drug Use Care CAA dated 08/21/25 documented Resident R11 had episodes of agitation and restlessness. The CAA documented staff attempted to redirect the resident and focus attention on something else when she became agitated. Resident R11's Care Plan, revised on 08/24/24 for dementia care and on 11/21/22 for activities, directed staff to be alert to triggers (specific triggers not listed) that would create negative behaviors or responses. The Care Plan directed staff to engage Resident R11 in conversation that was meaningful to her (Resident R11's interests not listed). The Care Plan directed staff that Resident R11 was not at ease joining other residents in activities, and directed staff to ensure Resident R11 attended two group activities per week and mingled with other residents and staff daily. The Care Plan directed staff to do one-on-one visitation with Resident R11 at least daily.On 08/26/25 at 01:15 PM, Resident R11 sat in her wheelchair in the TV area with other residents. Resident R11 was sleeping with her head down toward her chest.On 08/26/25 at 01:45 PM, Administrative Nurse D stated that staff had been working on the care plans. Administrative Nurse D stated Resident R11, as well as other residents' care plans, would be updated with person-centered interventions for dementia and activities.On 08/27/25 at 02:35 PM, Certified Nurse Aide (CNA) O stated that staff completed dementia training and education on Relias, but

she had not received specialized training on behaviors specific to dementia. CNA O stated she would just sit and talk and listen to the residents. CNA O stated she did not think Resident R11's care plan specified activities of interest to her or triggers that might cause behaviors.On 08/27/25 at 02:54 PM, Licensed Nurse (LN) F stated that Resident R11's care plan did list some activities to do with her, but that the care plan was not specific and person-centered. LN F stated that staff had been working on the care plans. LN F stated she would start working with the administrative nursing staff to ensure residents with dementia had a more person-centered care plan.The facility lacked a dementia care policy.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

17E445

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

17E445

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stanton County Health Care Facility Ltcu

404 N Chestnut Johnson, KS 67855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756

documented Resident R11 had a slow cognitive decline due to dementia.

Level of Harm - Minimal harm or potential for actual harm

Resident R11’s “Psychotropic Drug Use Care CAA” dated 08/21/25 documented Resident R11 had episodes of agitation and restlessness. Staff attempted to redirect the resident and focus attention on something else when she became agitated.

Residents Affected - Some Resident R11’s “Care Plan,” last revised 04/15/25, directed staff to give medications as directed. Resident R11’s “Care Plan” lacked staff direction on her digoxin (a medication used to treat CHF and heart rhythm problems) or her carvedilol (a beta-blocker). Resident R11’s “Orders” tab documented an order dated 01/10/24 for digoxin 125 micrograms (mcg) by mouth daily for atrial fibrillation. This order was discontinued on 05/01/25. Resident R11’s “Orders” tab documented an order dated 05/01/25 for digoxin 125 mcg (0.125 mg) tablet to administer 0.625 mg by mouth daily for atrial fibrillation.

Review of Resident R11’s May 2025 “Medication Administration Record (MAR)” revealed that Resident R11’s pulse rate was not obtained before the administration of digoxin on 31of 31 opportunities. Resident R11’s blood pressure was not obtained before the administration of her carvedilol on 31 of 31 opportunities.

Review of Resident R11’s June 2025 “MAR” revealed that Resident R11’s pulse rate was not obtained before the administration of digoxin on 30 of 30 opportunities.

Review of Resident R11’s July 2025 “MAR” revealed that Resident R11’s pulse rate was not obtained before the administration of digoxin on 31of 31 opportunities.

Review of Resident R11’s August 2025 “MAR” revealed that Resident R11’s pulse rate was not obtained before the administration of digoxin on 27of 27 opportunities.

Review of the Consultant Pharmacist’s MRR lacked a recommendation for pulse monitoring for digoxin use.

On 08/26/25 at 01:19 PM, Administrative Nurse D stated the facility had a monthly pharmacy and therapeutics meeting, which the pharmacist and physician were present. Administrative Nurse D stated the Pharmacist did a monthly review, which was in

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

17E445

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

17E445

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stanton County Health Care Facility Ltcu

404 N Chestnut Johnson, KS 67855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

condition characterized by cognitive decline accompanied by psychotic symptoms such as hallucinations and delusions), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), delirium (sudden severe confusion, disorientation, and restlessness), congestive heart disease (CHF- a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat).Resident R11's Annual Minimum Data Set (MDS) dated 08/08/25 documented

she had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. Resident R11 required partial/moderate assistance from staff for most activities of daily living (ADL). Resident R11 required substantial staff assistance with bathing. Resident R11 received an antipsychotic and an antidepressant medication regularly.Resident R11's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/21/25 documented Resident R11 had a slow cognitive decline due to dementia.Resident R11's Psychotropic Drug Use Care CAA dated 08/21/25 documented Resident R11 had episodes of agitation and restlessness. Staff attempt to redirect the resident and focus attention on something else when she becomes agitated. Resident R11's Care Plan, last revised 04/15/25, directed staff to give medications as directed. Resident R11's Care Plan lacked staff direction on her digoxin.Resident R11's Orders tab documented an order dated 01/10/24 for digoxin 125 micrograms (mcg) by mouth daily for atrial fibrillation. This order was discontinued on 05/01/25.Resident R11's Orders tab documented an order dated 05/01/25 for digoxin 125 mcg (0.125 mg) tablet to administer 0.625 mg by mouth daily for atrial fibrillation.Review of Resident R11's May 2025 Medication Administration Record (MAR) revealed that Resident R11's pulse rate was not obtained before the administration of digoxin on 31 of 31 opportunities. Review of Resident R11's June 2025 MAR revealed that Resident R11's pulse rate was not obtained before the administration of digoxin on 30 of 30 opportunities. Review of Resident R11's July 2025 MAR revealed that Resident R11's pulse rate was not obtained before the administration of digoxin on 31 of 31 opportunities. Review of Resident R11's August 2025 MAR revealed that Resident R11's pulse rate was not obtained before the administration of digoxin on 27of 27 opportunities. On 08/26/25 at 01:19 PM, Administrative Nurse D stated the physician did not monitor the pulse or blood pressure of every resident who was on an antihypertensive medication. Administrative Nurse D stated that all residents did get weekly vital signs taken, but not daily. Administrative Nurse D assumed the physician was aware of what medications required monitoring of the blood pressure or pulse according to the federal regulations, but could not be certain.The facility lacked a policy regarding unnecessary medications.

Event ID:

Facility ID:

17E445

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

17E445

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stanton County Health Care Facility Ltcu

404 N Chestnut Johnson, KS 67855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

The facility had a census of 22 residents. The Sample included 12 residents. Based on observation, record review, and interview, the facility failed to store drugs and biologicals for Resident (R) 4 according to policy

in the medication cart. This placed the resident at risk for an ineffective medication regimen.Findings included:- On 08/25/25 at 02:08 PM, during the medication room tour, the medication cart labeled with Resident R4's name contained a Lantus insulin pen without a name or date the insulin pen was put into use. Licensed Nurse (LN) G verified that the insulin pen should have a label with Resident R4's name and the date it was put into use.The facility's Medication Storage policy, dated 01/28/25, documented that no outdated or deteriorated medications are available for use in the facility. All such medications are destroyed. Drug containers having solid, illegible, worn, makeshift, incomplete, damaged, or missing labels will be returned to the pharmacy for proper labeling before storage.

Event ID:

Facility ID:

17E445

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

17E445

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stanton County Health Care Facility Ltcu

404 N Chestnut Johnson, KS 67855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

The facility had a census of 22 residents and one kitchen. The sample included 12 residents. Based on

observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 22 residents who reside in the facility and received their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.Findings included:- On 08/25/25 at 10:45 AM, Dietary staff preparing for the noon meal, Dietary Staff (DS) BB present in the kitchen. DS BB identified herself as

the Dietary Manager, was enrolled in a Dietary Manager Certification course, but had not yet finished the course. DS BB reported that the Registered Dietitian came to the facility monthly.The facility's Dietitian policy, dated 01/2025, documented that a qualified dietitian would help oversee clinical nutritional dietary services in the facility. A dietitian's qualification shall be based upon: Registration by the Commission on Dietetic Registration of the American Dietetic Association, or demonstrated education, training, or experience in the identification of dietary needs, planning, and implementation of dietary programs.

Event ID:

Facility ID:

17E445

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

17E445

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stanton County Health Care Facility Ltcu

404 N Chestnut Johnson, KS 67855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited STANTON COUNTY HEALTH CARE FACILITY LTCU in JOHNSON, KS for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-08-28.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of STANTON COUNTY HEALTH CARE FACILITY LTCU.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.