Stanton County Health Care Facility Ltcu

thirty (30) day advance notice of the transfer or discharge. A transfer or discharge notice would

resident’s right to appeal the transfer or discharge to the State; and the name, address, and

will be recorded in the resident’s clinical record. - R20's Electronic Medical Record (EMR) included diagnoses of disorientation, urinary tract infection (UTI- an 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).

R20’s “Minimum Data Set” (MDS) dated [DATE] 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 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 R20 was readmitted to the long-term care unit, via wheelchair.

On 08/26/25 at 08:20 AM, 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.

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Stanton County Health Care Facility Ltcu 404 N Chestnut Johnson, KS 67855

01:53 PM, R3 sat in her wheelchair in her room, holding a bible in her hands. R3 reported she was

Service X reported that the Licensed Master Social Worker (LMSW) was contracted, did not come to

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.

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Stanton County Health Care Facility Ltcu 404 N Chestnut Johnson, KS 67855

Based on observation, record review, and interview, the facility failed to

(R) 11's dementia (a progressive mental disorder characterized by failing memory, confusion) diagnosis.

This deficient practice placed R11 at risk of ineffective treatment and decreased quality of care.

Findings included:- 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).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. R11 required partial/moderate assistance from staff for most activities of daily living (ADL). R11 required substantial staff assistance with bathing. R11 received an antipsychotic and an antidepressant medication regularly.R11's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/21/25 documented R11 had a slow cognitive decline due to dementia.R11's Psychotropic Drug Use Care CAA dated 08/21/25 documented 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.

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 R11 in conversation that was meaningful to her (R11's interests not listed).

The Care Plan directed staff that R11 was not at ease joining other residents in activities, and directed staff to ensure 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 R11 at least daily.On 08/26/25 at 01:15 PM, R11 sat in her wheelchair in the TV area with other residents.

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 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 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 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.

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Stanton County Health Care Facility Ltcu 404 N Chestnut Johnson, KS 67855

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

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

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

Review of R11’s August 2025 “MAR” revealed that 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

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Stanton County Health Care Facility Ltcu 404 N Chestnut Johnson, KS 67855

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

Review of R11's August 2025 MAR revealed that 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.

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Stanton County Health Care Facility Ltcu 404 N Chestnut Johnson, KS 67855

Based on observation,

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 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 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.

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Stanton County Health Care Facility Ltcu 404 N Chestnut Johnson, KS 67855

the food and nutrition service, including a qualified dietician.

on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary

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.

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Stanton County Health Care Facility Ltcu 404 N Chestnut Johnson, KS 67855

infection control interventions designed to reduce transmission of resistant organisms, which employ

urinary catheter (tube placed in the bladder to drain urine into a collection bag) and shared use of a full body lift sling.

This deficient practice placed the residents who reside in the facility at risk of infectious disease processes.

Findings included:- R1's Electronic Medical Record (EMR), documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), urinary tract infection (UTI- an infection in any part of the urinary system), right thigh blister, neuromuscular dysfunction of the bladder(the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), edema(swelling resulting from an excessive accumulation of fluid in the body tissues), acute cystitis (inflammation of the bladder) with hematuria (blood in the urine), and chronic pain.R1's Quarterly Minimum Data Set dated 07/11/25, documented that R1 had severe cognitive impairment, an altered level of consciousness that fluctuated, and had not exhibited behaviors. R1 was dependent on staff for all functional abilities and mobility.

The MDS further documented that R1 had an indwelling catheter and was frequently incontinent of bowel. R1 also received an antibiotic (a class of medications used to treat infections).R1's Care Plan dated 07/14/25, documented R1 had a risk for healthcare-acquired infections due to a medical device, as evidenced by an indwelling catheter.

The Care Plan directed staff to change the catheter monthly, drain the catheter bag every shift, as needed, and continue to adhere to other infection prevention measures.

The Care Plan directed gowns and gloves were to be used during high-contact activities with increased risk for Multidrug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics) transmission, during dressing, bathing, transfers, providing hygiene, changing briefs, and assisting with toileting.The Physician Order dated 07/23/24, directed staff to implement Enhanced Barrier Precautions.The Physician Order dated 07/03/25, directed staff to change the catheter monthly, using sterile technique.The Progress Note dated 08/15/25 at 11:34 AM, documented two blisters with one intact and one open under the catheter secure adhesive.The Progress Note dated 08/17/25, documented R1's brief was wet, the catheter was advanced, and ten milliliters of sterile saline were used to inflate the balloon. On 08/26/25 at 09:36 AM, Certified Nurse Aide (CNA) M and CNA N took R1 to her room and donned disposable gloves and gowns.

Staff utilized a full-body mechanical lift to transfer R1 from her wheelchair to the toilet, pulling the brief loose, and sat R1 on the toilet. CNA M and CNA N provided R1 with toileting hygiene, reattached the brief, and then placed R1 in bed.

Once finished with positioning the resident, CNA M took the lift and sling out of the room. CNA M reported the sling used with R1 was also utilized for two other residents. On 08/27/25 at 10:14 AM, Administrative Nurse E reported the facility should purchase a sling lift for single use of R1, who had an indwelling catheter.The facility's Enhanced Barrier Precautions policy, dated 03/27/25, documented that the facility follows recommendations and guidance from the Centers for Disease Control in order to keep residents as safe from Healthcare Acquired Infections (HAI).

Multidrug-resistant organism (MDRO) transmission is common in nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs.

Enhanced Barrier Precautions (EBP) are implemented as one intervention this facility uses to reduce transmission of resistant organisms, which employs targeted Personal Protective Equipment (PPE) use during high-contact resident care activities.

Standard Precautions continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status.