Family Health & Rehabilitation Center
Family Health & Rehabilitation Center in WICHITA, KS — inspection on March 4, 2026.
Found 7 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
assessed for the ability to safely self-administer his physician-ordered Fluticasone propionate nasal
R12's Electronic Medical Record (EMR) documented diagnoses of allergic rhinitis, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and unspecified dementia (progressive mental disorder characterized by failing memory, confusion).R12's Annual Minimum Data Set (MDS) dated 10/06/25 documented he had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R12 used a wheelchair to assist with mobility and had no impairment in upper or lower extremities.R12's Quarter MDS dated 01/06/26 documented a BIMS score of 13, which indicated intact cognition. R12 used a walker or wheelchair to assist with mobility and had no impairment in upper or lower extremities.R12's Psychotropic Drug Use Care Area Assessment (CAA) dated 10/06/25 documented he had his medications managed and overseen by the nurse and physician team.R12's Care Plan lacked documentation he kept Fluticasone Propionate Nasal Spray at his bedside.Review of R12's physician orders documented Fluticasone Propionate Nasal Suspension 50 micrograms per action, spray once in both nostrils one time a day for allergic rhinitis, dated 10/03/24.R12's Assessment tab lacked the Self-Administration of Medication/Treatment Data Collection Tool for Fluticasone Propionate Nasal Spray.On 03/02/26 at 09:09 AM, R12 was seated in his recliner with his feet raised, listening to music. On the dresser right in front of his recliner sat a bottle of Fluticasone Propionate Nasal Spray. R12 stated he did his own nasal spray. R12 reported the nasal spray was not on a schedule, and he took it when he was stopped up.On 03/04/26 at 11:25 AM, the Fluticasone Propionate Nasal Spray sat on R12's dresser.
Licenses Nurse (LN) H confirmed that is what was on R12's dresser and that if he had that in his room, he would have been assessed to keep the medication in his room. LN H reviewed R12's chart and confirmed that he did not have the assessment to keep Fluticasone Propionate Nasal Spray in his room. LN H stated she would get that off of R12's dresser and remove it from his room due to him not having the assessment indicating he could keep it in his room.On 03/04/26 at 12:28 PM, Administrative Nurse D stated that if there was no assessment completed for self-administration of the medication, then the resident could not keep any medications in his room.
Administrative Nurse D stated R12 should not have had the nasal spray in his room.The facility's undated Self-Administration of Medication policy documented self-administration of medications by residents was generally allowed.
The policy documented the competency of the resident was assessed prior to allowing a resident to self-administer medications by the interdisciplinary team.
The procedure directed that an assessment would be performed annually and after a significant change of condition.
175501 03/04/2026
Family Health & Rehabilitation Center 639 S Maize Court Wichita, KS 67209
Based on record review and interviews,
Electronic Medical Record (EMR) recorded diagnoses of irritable bowel syndrome, hypertension (high blood pressure), chronic respiratory failure, and urine retention.R65's admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition.
The MDS noted R65 was dependent upon staff assistance for toileting, dressing, and transfers.
She had one non-injury fall.R65'S 12/18/25 Falls Care Area Assessment (CAA) triggered secondary to impaired balance with transitions and transfers and her need for assistance with activities of daily living.
The CAA noted contributing factors included restricted mobility, medication usage, a need for assistance with transfers and a urinary catheter (tube inserted into the bladder to drain urine).
Her risk factors included falls and injuries from falls, pain, and skin breakdown. A care plan would be reviewed to assist in preventing falls and injuries related to falls. R65's Care Plan recorded one Focus, related to activities initiated on 12/08/25.
The interventions, initiated on 12/08/25, directed staff to assist R65 to and from activities and to educate the resident daily of the available activities.
The plan lacked further Focus areas, goals or interventions.On 03/04/26 at 08:36 AM, Licensed Nurse (LN) J reported that the MDS nurse would complete the comprehensive care plan within 21 days of admission.On 03/04/26 at 09:40 AM, Administrative Nurse E stated R65's Care Plan should have been completed in the timeframe of 21 days and said that R65 had moved the skilled side to the long-term care side around the holidays.
Administrative Nurse E stated she had not realized R65's comprehensive plan had not been developed. On 03/04/26 at 01:55 PM, Administrative Nurse D said she expected the admission comprehensive care plan to be completed within 21 days of admission.The facility provided the policy Care Plan Revisions revised on 01/18/26, which noted the Care Planning process included patient assessment, goal setting, interventions, referrals to other health care professionals, evaluation of patient responses to treatment and revision of care and treatment in order to meet the patient's needs.
175501 03/04/2026
Family Health & Rehabilitation Center 639 S Maize Court Wichita, KS 67209
Observation on 03/03/26 at 07:50 AM revealed staff assisted R39 with morning care but did not offer oral care at that time.
Observation on 03/03/26 at 08:15 AM revealed R39 had a battery-operated toothbrush as well as toothpaste in his bathroom in an emesis basin.
The emesis basin and the toothbrush were dry. On 03/02/26 at 10:31 AM, R39's representative reported she was concerned that the staff does not perform oral care on R39 as they should.
She reported that she did address these concerns at the care plan meeting she attended about a month ago. On 03/03/26 at 10:23 AM, Licensed Nurse (LN) I reported that he did not provide oral care to R39. He just signed it off on the treatment record and followed up with the aides to make sure they completed it during morning care. On 03/03/26 at 12:08 PM, Certified Nurse Aide (CNA) M reported that she would usually do R39's oral care after breakfast.
CNA M said she did not provide R39 oral care that day as she forgot to do it. CNA M verified that R39 could not brush his own teeth. On 03/04/26 at 09:12 AM, Administrative Nurse D revealed she expected the staff to complete R39's oral care.
The facility policy Oral Health Care, revised 02/10/25 documented every resident will receive oral care twice daily to ensure the highest level of oral health and oral function.
175501 03/04/2026
Family Health & Rehabilitation Center 639 S Maize Court Wichita, KS 67209
assessment until the resident had a BM.
The facility's policy Bowel and Bladder Management, revised
bowel report at the beginning of the shift and initiate the bowel protocol when indicated.
When a
the resident, including: the date and description of last bowel movement, presence of abdominal pain, cramping, nausea, or vomiting, bowel sounds and abdominal assessment, recent dietary and fluid intake, current medications, vital signs and signs of dehydration and stool characteristics (color, consistency, presence of blood, etc.).
The bowel protocol is as follows:Step 1: Administer Milk of Magnesia (MOM) 30 ml orally.Step 2: If no bowel movement occurs within 24 hours, administer lactulose 20 ml orally every 2 hours for up to three (3) doses or until bowel movement occurs.Step 3: If no bowel movement occurs after lactulose administration, administer Dulcolax(Bisacodyl) suppository 10 mg per rectum.Step 4: If no bowel movement occurs following the suppository, administer one (1) Fleet enema.Step 5: If there is still no bowel movement following the above interventions, notify the provider for further evaluation and treatment orders.
175501 03/04/2026
Family Health & Rehabilitation Center 639 S Maize Court Wichita, KS 67209
Findings included: - R4's Electronic Medical Record (EMR) documented R4 had diagnoses of artificial openings of the gastrointestinal tract (surgical creation of an artificial opening into the stomach through the abdominal wall) R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition.
The MDS documented R4 required total staff assistance with activities of daily living (ADLS), had no swallowing disorders, and received tube feedings. R4's Care Plan, revised on 02/17/26, documented R4 dependent with tube feeding and water flushes and instructed staff to provide them per the physician's order.
The Physician Order, dated 01/12/26, instructed staff to administer one carton (250 milliliters (ml) of Nutrent 2.0 (nutrition supplement that provides complete, balanced nutrition for long - or short -term tube feeding with increased calorie and protein needs) daily at 10:00 AM and flush the tube with 100ml of free water before and after each bolus feeding. On 03/03/26 at 10:45 AM, observation revealed Licensed Nurse (LN) G, placed gloves on, placed a catheter tip syringe into R4's feeding tube, poured 50 ml of free water, administered R4's Zofran (dissolved in 15 ml of water) through the peg tube, provided 250 ml of Nutrent supplement through the tube, then flushed with 50 ml of water. On 03/03/26AM at 10:45 AM, LN G verified she had flushed R4's peg tube with 50 ml before and after R4's administration of Zofran, and 0 ml before peg tube feeding. LN G stated she had read the order wrong and should have flushed R4's peg tube with 100 mL before and after the peg tube feeding. On 03/04/26 at 11:02 AM, Administrative Nurse D stated she would expect the staff to verify the order, check placement, position the resident in the proper position, flush with water per physician order, give medication and supplement, then flush with physician ordered amount of water.
The facility's Enteral Tube Feeding Policy, dated 12/12/23, documented for bolus supplementation, the pharmacy or facility would encode orders into the computer under the medication order entry program.
Labeling and dispensing would be as with unit-dose medications.
175501 03/04/2026
Family Health & Rehabilitation Center 639 S Maize Court Wichita, KS 67209
Based on observation, record review, and
contamination.
Findings included:- During the initial kitchen inspection on 03/02/26 at 07:35 AM, observation in the food storage room on main hall revealed several cases of water stored directly on the floor.
Dietary BB reported the emergency water had been on the floor for a few months.On 03/02/26 at 07:40 AM, observation in [NAME] House revealed the oven had a large amount of burnt dark residue on the bottom.
The refrigerator had a staff member's lunch bag at the bottom.
Dietary BB removed the lunch bag of the staff member and reported it should be stored in the employee refrigerator. On 03/02/26 at 07:51 AM, the [NAME] and [NAME] House refrigerator had an undated container of cut up apples with cinnamon and an undated bag of hash browns.
The freezer had an undated bag of frozen biscuits.
Dietary CC reported that all items should be labeled with a date. On 03/03/26 at 12:56 PM, observation of the [NAME] and [NAME] kitchens revealed broken cupboards, scratched cutting boards and the muffin bakery tins were bent with cooked on dark black/brown residue.
The bottom shelf of the freezer in the actual kitchen was quite dirty with drops of food and liquids. On 03/03/26 at 01:05 PM, observation in the [NAME] and [NAME] kitchen revealed missing drawers.
The cutting boards were very scratched up, and the muffin bakery tins were bent with cooked on dark black/brown residue.
Under the steamer table in [NAME], the shelf was dirty with baked food and dust.
There was a broken laundry basket on the floor in the storage area between [NAME] and [NAME] labeled kitchen towels, and the basket contained clean kitchen towels.
Dietary BB reported that the dietary staff use the laundry area located in each house and confirmed the basket should not be on the ground.
Dietary BB reported that the cutting boards and the bakeware would be replaced.On 03/03/26 at 03:00 PM, Administrative Staff A reported she expected the kitchen equipment to be clean and the kitchen to be in good repair.
She expected the food to be labeled with a date and items not to be stored on the floor.
The facility's policy Food Preparation and Handling Policy revised 01/20/26, noted all food items and products served to elders that will be prepared or served from/in a central kitchen and/or neighborhood kitchen/serving area will be according to standardized recipes.
Food items will be prepared using methods and techniques designed to preserve maximum nutritive value, enhance flavor, and be free of injurious organisms and substances.
The kitchen and equipment would be kept clean, neat, orderly and well maintained.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
175501 03/04/2026
Family Health & Rehabilitation Center 639 S Maize Court Wichita, KS 67209
Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly.
Findings included:- On
and one on the west side.
The garbage receptacle outside of the [NAME] House had the lid open on one side, and there were several bags of garbage behind the dumpster that had holes in them as if broken open, gloves, food, and other medical supplies noted.
There was garbage on the ground on the side of the dumpster.
Dietary CC reported that the lids should always be closed, and the garbage behind and on the side of the container should not be there. On 03/03/2026 at 10:35 AM, Dietary BB reported that there should be no garbage on the ground at the trash dumpsters and the lids should be closed. On 03/03/2026 at 12:30 PM, Administrative Staff A reported that she had been working on a little project regarding the dumpster.
She stated the dumpster that had garbage on the ground around it was small, and she was trying to get a new one.
She reported she expected the staff to close the lids and not have garbage on the ground.
The facility's policy Disposal of Garbage and Refuse Policy, revised on 01/14/26, documented the facility would maintain all outside dumpsters and surrounding refuse storage areas in a clean, sanitary, and well-maintained condition to prevent the creation of a nuisance, pest attraction, or potential contamination risk to food service operations, residents, staff, or visitors.