Inspection Reports for
Halstead Health and Rehabilitation Center
915 MCNAIR STREET, HALSTEAD, KS, 67056
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
68% occupied
Based on a May 2024 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 41
Deficiencies: 13
Date: May 20, 2024
Visit Reason
Routine inspection of Halstead Health and Rehabilitation Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to provide dignified care, incomplete care plans, inaccurate assessments, unsafe environment, improper medication management, inadequate infection control, and failure to maintain sanitary conditions in food storage and facility areas.
Deficiencies (13)
F 0550: The facility failed to ensure Resident 13 received care in a dignified manner during incontinent care when the window blind was left open, risking decreased psychosocial well-being.
F 0578: The facility failed Resident 16 by having the guardian sign a completed Do Not Resuscitate order without judicial approval.
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment due to frayed carpeting, loose sewer cleanout cap, broken tiles, and unknown black substance in showers.
F 0641: The facility failed to accurately complete the Minimum Data Set for Residents 9 and 19, placing them at risk for uncommunicated care needs.
F 0656: The facility failed to develop comprehensive care plans for Residents 13, 19, 26, and 42 related to pressure ulcers, respiratory equipment, psychotropic medication monitoring, and dysphagia.
F 0677: The facility failed to ensure Resident 13 received care for removal of facial hair, placing the resident at risk for decreased psychosocial well-being.
F 0686: The facility failed to assess and provide timely treatment for Resident 13's pressure ulcers, delaying care and risking worsening of wounds.
F 0689: The facility failed to ensure a safe environment for Resident 35 by not checking the temperature of soup before serving, resulting in burns with blisters on two fingers.
F 0695: The facility failed to properly clean and store nebulizers for Residents 19 and 30, failed to properly store CPAP for Resident 42, and failed to provide adequate tracheostomy care for Resident 26, risking respiratory illness and emergencies.
F 0756: The facility failed to follow up timely on pharmacist medication regimen review recommendations for Residents 8, 24, 26, 33, and 35, placing residents at risk for unnecessary medications.
F 0812: The facility failed to store foods safely and under sanitary conditions by not dating or resealing open food items and failing to clean thermometer between food temperature checks.
F 0880: The facility failed to maintain an effective infection control program by not implementing enhanced barrier precautions for Residents 13, 24, and 26, and improper cleaning and storage of respiratory equipment for Residents 19, 30, and 42.
F 0921: The facility failed to provide a sanitary environment by not having lids on linen cans in shower rooms, biohazard container in soiled utility room, and failure to maintain appropriate flooring in laundry area.
Report Facts
Residents census: 41
Sampled residents: 12
Pressure ulcer size: 0.5
Pressure ulcer size: 0.3
Pressure ulcer size: 0.2
Pressure ulcer size: 0.2
Soup temperature: 154
Medication regimen review response delay: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Verified medication regimen review process and deficiencies in cleaning nebulizer and infection control | |
| Administrative Nurse C | Provided information on care plan updates and wound care orders | |
| Consultant Nurse P | Confirmed infection control deficiencies and lack of policy implementation | |
| Certified Nurse Aide N | CNA | Observed care deficiencies including facial hair removal and barrier cream application |
| Certified Medication Aide U | CMA | Observed care deficiencies including barrier cream application and incontinent care |
| Licensed Nurse L | LN | Performed tracheostomy care and described nebulizer cleaning procedures |
| Dietary Staff J | Observed food temperature and food storage deficiencies | |
| Maintenance Director F | Identified environmental safety and sanitation deficiencies |
Inspection Report
Routine
Census: 41
Deficiencies: 13
Date: May 20, 2024
Visit Reason
Routine inspection of Halstead Health and Rehabilitation Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity, care planning, infection control, medication management, environmental safety, and food safety. Specific failures included undignified care practices, incomplete care plans, improper cleaning and storage of respiratory equipment, failure to implement enhanced barrier precautions, delayed treatment of pressure ulcers, unsafe food handling, and inadequate environmental sanitation.
Deficiencies (13)
F 0550: The facility failed to ensure Resident R13 received care in a dignified manner during incontinent care when the window blind was left open, risking decreased psychosocial well-being.
F 0578: The facility failed Resident R16 by having the guardian sign a completed Do Not Resuscitate order without judicial approval.
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment due to frayed carpeting, loose sewer cleanout cap, broken tiles, and unknown black substance in showers.
F 0641: The facility failed to accurately complete the Minimum Data Set for Residents R9 and R19, placing them at risk for uncommunicated care needs.
F 0656: The facility failed to develop comprehensive care plans for Residents R13's pressure ulcer, R19's respiratory equipment, R42's dysphagia, and R26's psychotropic medication monitoring.
F 0677: The facility failed to ensure Resident R13 received care for removal of facial hair, placing the resident at risk for decreased psychosocial well-being.
F 0686: The facility failed to assess and provide timely treatment for Resident R13's pressure ulcer, delaying care and risking worsening of the condition.
F 0689: The facility failed to ensure a safe environment for Resident R35, who suffered burns from placing fingers in hot soup that was not temperature checked before serving.
F 0695: The facility failed to provide proper respiratory care for Residents R19, R26, R30, and R42, including improper cleaning and storage of nebulizers and CPAP, and inadequate tracheostomy care.
F 0756: The facility failed to follow up timely on pharmacist recommendations for Residents R8, R24, R26, R33, and R35, placing residents at risk for unnecessary medications.
F 0812: The facility failed to store foods safely and under sanitary conditions, including failure to date and reseal open food items and failure to clean thermometer between food items.
F 0880: The facility failed to maintain an effective infection control program, including failure to implement enhanced barrier precautions for Residents R13, R24, and R26.
F 0921: The facility failed to provide a sanitary environment by failing to have lids on linen cans and biohazard containers and failure to maintain appropriate flooring in laundry area.
Report Facts
Resident census: 41
Sampled residents: 12
Pressure ulcer size: 0.5
Pressure ulcer size: 0.3
Pressure ulcer size: 0.2
Temperature: 154
Medication response time: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Verified multiple deficiencies including medication regimen review delays and respiratory care issues |
| Consultant Nurse P | Consultant Nurse | Confirmed infection control deficiencies and respiratory care issues |
| Licensed Nurse L | Licensed Nurse | Performed tracheostomy care and described nebulizer cleaning procedures |
| Certified Nurse Aide N | Certified Nurse Aide | Observed providing incontinent care and reported facial hair removal practices |
| Certified Medication Aide U | Certified Medication Aide | Observed providing incontinent care and described nebulizer handling |
| Dietary Staff J | Dietary Staff | Observed heating and serving food without temperature checks |
| Maintenance Director F | Maintenance Director | Identified environmental sanitation deficiencies |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 8
Date: Oct 6, 2022
Visit Reason
The inspection was conducted as an annual survey of Halstead Health and Rehabilitation Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including wound care, peri-care hygiene, respiratory care, medication management, food safety, housekeeping, and maintenance. Several failures to follow physician orders and facility policies were noted, along with sanitary and safety concerns.
Deficiencies (8)
F 0684: The facility failed to provide adequate non-pressure wound care to resident R188, including lack of physician orders and improper wound cleansing, risking infection.
F 0690: The facility failed to provide sanitary peri-care and proper glove use for resident R5, risking urinary tract infections.
F 0695: The facility failed to obtain a physician order for oxygen administration for resident R27, compromising respiratory care.
F 0755: The facility failed to obtain a physician's order to discontinue insulin for resident R4 and failed to notify the physician of the resident's improved status.
F 0757: The facility failed to administer PRN medications for constipation to resident R6 and failed to obtain ordered labs for resident R17.
F 0812: The facility failed to maintain food preparation equipment clean and failed to ensure a two-inch air gap between ice machine drainage pipes and floor drain.
F 0814: The facility failed to ensure trash was contained in the dumpster with lids closed, risking spread of infection.
F 0921: The facility failed to maintain a sanitary, orderly environment in storage closets by storing supplies directly on the floor and lacked a policy for supply storage.
Report Facts
Resident census: 36
Residents selected for review: 15
Blood glucose range: 43
Blood glucose range: 372
Milk of Magnesia days without BM: 4
Ice machine air gap: 0
Oven cleaning interval: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Named in wound care and oxygen order deficiencies |
| Certified Medication Aide R | Certified Medication Aide | Named in peri-care deficiency |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding multiple deficiencies including wound care, oxygen orders, medication management, and storage policies |
| Consultant HH | Consultant Nurse | Interviewed regarding oxygen order and physician order policies |
| Certified Nurse Aide M | Certified Nurse Aide | Interviewed regarding bowel movement documentation |
| Certified Nurse Aide N | Certified Nurse Aide | Interviewed regarding bowel movement documentation |
| Dietary Staff BB | Dietary Staff | Interviewed regarding oven cleaning schedule |
| Maintenance Staff U | Maintenance Staff | Interviewed regarding ice machine drainage and dumpster lids |
Inspection Report
Routine
Census: 27
Deficiencies: 6
Date: Apr 6, 2021
Visit Reason
Routine inspection of Halstead Health and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, personal care, skin care, respiratory care, medication management, and diagnostic test result communication.
Findings
The facility failed to provide privacy during care for one resident, failed to provide appropriate personal hygiene assistance for nail care, failed to provide thorough skin assessments for pressure ulcer risk, failed to properly clean and store respiratory equipment, failed to notify physicians of out-of-range blood sugar levels, and failed to promptly communicate radiology test results to a resident.
Deficiencies (6)
F 0550: The facility failed to provide privacy for Resident 28 while staff provided cares, leaving the door open and resident uncovered.
F 0677: The facility failed to ensure Resident 19 received appropriate personal hygiene assistance needed for trimming and cleaning of fingernails.
F 0684: The facility failed to provide a thorough skin assessment for adequate monitoring of Resident 28's red, broken skin on posterior thighs.
F 0695: The facility failed to clean oxygen concentrator filters weekly, store oxygen nasal cannulas properly, and clean nebulizer kits for Residents 8, 16, 19, and 21.
F 0757: The facility failed to notify the physician for further instruction when Resident 28's blood sugar levels were out of parameters multiple times in March 2021.
F 0777: The facility failed to provide Resident 12 with prompt and timely results of his radiology diagnostic test.
Report Facts
Resident census: 27
Residents reviewed: 12
Blood glucose levels out of parameters: 4
Insulin dose: 39
Insulin dose: 70
Skin abrasion size: 1.5
Skin abrasion size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Confirmed staff should cover resident when door open and discussed oxygen equipment cleaning and notification procedures |
| Licensed Nurse G | Licensed Nurse | Confirmed oxygen concentrator filter cleaning and nasal cannula storage procedures |
| Certified Nurse Aide M | Certified Nurse Aide | Observed leaving Resident 28 uncovered with door open during care |
| Certified Nurse Aide N | Certified Nurse Aide | Assisted with Resident 28 care and reported ointment use |
| Certified Nurse Aide O | Certified Medication Aide / Certified Nurse Aide | Reported zinc ointment application and oxygen cannula storage |
| Licensed Nurse H | Licensed Nurse | Discussed notification of blood sugar out-of-range and radiology results to residents |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 3, 2012
Visit Reason
The inspection was conducted as a health survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 15, 2011
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies at the facility.
Findings
The report documents that previously reported deficiencies have been corrected as of the revisit date. Specific corrections are identified by regulation numbers and completion dates.
Deficiencies (1)
Regulation 28-39-162(a) deficiency was corrected by 09/15/2011.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 15, 2011
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple cited regulations.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 1
Date: Aug 16, 2011
Visit Reason
The inspection was conducted as part of the annual Health Resurvey and included a complaint investigation related to resident care and facility compliance.
Complaint Details
The complaint investigation involved a resident being left unattended on the toilet without access to the call light for at least 45 minutes on three reported occasions. The resident reported the incidents and staff acknowledged the failure to provide the call light. Maintenance staff and administrative licensed nurse were aware of the issue.
Findings
The facility failed to ensure an accessible emergency call light next to a resident's toilet, resulting in the resident being left unattended on the toilet without a call light for at least 45 minutes on multiple occasions. Staff were aware of the issue but did not promptly correct it until maintenance moved the call light closer to the toilet.
Deficiencies (1)
28-39-162(a) Physical Environment: The facility failed to install an accessible resident emergency call button next to the toilet in one resident's bathroom, leaving the resident unable to call for assistance while on the toilet.
Report Facts
Resident census: 50
Residents selected for review: 15
Duration unattended: 45
Reported incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Q | Certified Nurse Aide | Named in incident of leaving resident unattended without call light |
| CNA X | Certified Nurse Aide | Named in incident of leaving resident unattended without call light |
| Nurse B | Administrative Licensed Nurse | Became aware of inaccessible call light issue |
| Staff O | Maintenance Staff | Reported knowledge of incident and moved call light |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040009 POC 9NGC11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for Halstead Health.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder for the Plan of Correction with no records found.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040009 POC ELFK11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific findings are detailed in this document; it serves as a corrective action plan following a prior inspection.
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