Inspection Reports for Kansas Christian Home
1035 SE 3RD STREET, KS, 67114-3904
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 5, 2014, found that all previously cited deficiencies had been corrected. Earlier inspections identified issues primarily related to emergency call systems, resident assessments, medication management, and timely reporting of alleged abuse. Complaint investigations substantiated failures in assessing and reporting resident injuries and medication administration errors, as well as delays in abuse reporting and inadequate protective actions during investigations. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with corrective actions verified and no deficiencies noted in the latest inspection.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
20.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
245% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
80 residents
Based on a March 2014 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 12
Jun 5, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
All deficiencies previously cited in the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date, June 5, 2014.
Deficiencies (12)
| Description |
|---|
| Deficiency identified by ID Prefix F0156 related to regulations 483.10(b)(5) - (10), 483.10(b)(1) |
| Deficiency identified by ID Prefix F0250 related to regulation 483.15(g)(1) |
| Deficiency identified by ID Prefix F0253 related to regulation 483.15(h)(2) |
| Deficiency identified by ID Prefix F0272 related to regulation 483.20(b)(1) |
| Deficiency identified by ID Prefix F0278 related to regulation 483.20(a) - (i) |
| Deficiency identified by ID Prefix F0279 related to regulations 483.20(d), 483.20(k)(1) |
| Deficiency identified by ID Prefix F0280 related to regulations 483.20(d)(3), 483.10(k)(2) |
| Deficiency identified by ID Prefix F0309 related to regulation 483.25 |
| Deficiency identified by ID Prefix F0312 related to regulation 483.25(a)(3) |
| Deficiency identified by ID Prefix F0371 related to regulation 483.35(i) |
| Deficiency identified by ID Prefix F0412 related to regulation 483.55(b) |
| Deficiency identified by ID Prefix F0431 related to regulations 483.60(b), (d), (e) |
Inspection Report
Re-Inspection
Deficiencies: 5
Jun 5, 2014
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report shows that all previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected by the revisit date of 06/05/2014.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) |
| Deficiency related to regulation 26-40-303 (h) |
| Deficiency related to regulation 26-40-303 (I)(i)(ii)(iii)(iv) |
| Deficiency related to regulation 26-40-303 (2)(a)(i)(ii)(iii) |
| Deficiency related to regulation 26-40-305 (c)(1)(2) |
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 18
Apr 24, 2014
Visit Reason
This document is a Plan of Correction submitted by Kansas Christian Home in response to deficiencies cited in a prior survey. It outlines corrective actions to address compliance issues identified during the survey.
Findings
The plan addresses multiple deficiencies related to resident rights notifications, dental care follow-up, labeling in co-mingled bathrooms, comprehensive assessments including oral exams, care plan updates for falls and dialysis protocols, medication management including expired medications and gradual dose reductions, sanitation standards, call light system maintenance, emergency pull cords, and environmental safety such as ventilation in the beauty shop.
Severity Breakdown
D: 9
E: 6
F: 3
G: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights regarding Medicare Non-Coverage of services | D |
| Inadequate follow-up on dental request letters | D |
| Bathroom items not labeled in co-mingled bathrooms | E |
| Lack of comprehensive assessments including oral exams | D |
| Inaccurate gathering of resident information and assessments in MDS | D |
| Care plans lacking targeted behaviors and interventions | D |
| Care plans not updated with interventions after falls | D |
| Dialysis protocols missing from care plans and treatment MAR | D |
| Oral care not provided routinely or as requested | D |
| Incomplete fall investigations and unsecured chemicals | G |
| Failure to perform gradual dose reductions and update care plans accordingly | E |
| Improper sanitation standards in handling utensils, thermometers, and thickened liquids | E |
| Expired medications present on medication carts | E |
| Call light system not differentiating emergent and non-emergent calls | F |
| Lack of policy and maintenance for call light system | F |
| Emergency pull cords not installed within resident reach | F |
| Automatic sliding door alarm not installed | E |
| Inadequate ventilation in beauty shop | E |
Report Facts
Corrective action completion date: Apr 24, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JIM NACHTIGAL | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| IRINA STRAKHOVA | Added and modified Plan of Correction |
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 5
Mar 25, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with nursing facility regulations and to verify correction of previous deficiencies.
Findings
The facility failed to have an emergency call system that differentiated between emergent and non-emergent areas, lacked a preventative maintenance program for weekly testing of the call light system, did not have emergency call buttons within resident reach next to showers and bathtubs, failed to alarm an interior door leading to an assisted living facility, and did not ensure adequate ventilation in the beauty shop.
Severity Breakdown
SS=F: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to have an emergency call system that distinguished between emergent and non-emergent care areas and lacked a policy to ensure high-priority response to emergency calls. | SS=F |
| Failed to have a preventative maintenance program including weekly testing of the call light system. | SS=F |
| Failed to have an emergency call button within resident reach next to each shower or bathtub. | SS=F |
| Failed to ensure an interior door to another adult care home was electronically monitored and alarmed when opened. | SS=E |
| Failed to ensure adequate ventilation in the beauty shop; exhaust fan was not used properly and no policy was provided. | SS=E |
Report Facts
Facility census: 80
Independently mobile residents: 54
Residents receiving beauty shop services: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff KK | Maintenance staff interviewed about call light system functionality. | |
| Staff Z | Maintenance staff interviewed about call light system and maintenance. | |
| Staff B | Administrative nursing staff | Interviewed regarding call light system and door alarm policies. |
| Staff A | Administrative staff | Confirmed shower call light deficiencies. |
| Staff X | Licensed nursing staff | Reported door alarm functionality and monitoring. |
| Staff LL | Licensed nursing staff | Reported door alarm behavior and reset procedures. |
| Staff C | Beauty shop staff | Interviewed about ventilation fan operation in beauty shop. |
Inspection Report
Follow-Up
Deficiencies: 2
Feb 15, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report confirms that the deficiencies previously cited under regulations 483.25 and 483.60(a),(b) were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.60(a),(b) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Feb 15, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Kansas Christian Home.
Findings
The plan addresses deficiencies related to skin issue assessments and medication patch administration errors, including staff re-education, disciplinary actions, and implementation of new documentation procedures.
Complaint Details
This Plan of Correction is linked to a complaint investigation at Kansas Christian Home.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to properly assess and report skin issues in residents. | D |
| Medication errors related to patch placement and removal. | D |
Report Facts
Complete Date: Feb 15, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Nachtigal | CEO | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Jan 30, 2014
Visit Reason
The inspection was conducted as a result of complaint investigations #71508, 70047, 71526, and 71518 to assess the facility's compliance with care and pharmaceutical service requirements.
Findings
The facility failed to promptly identify and provide services for significant bruising and swelling of one resident's extremities and chest, and failed to accurately administer nitroglycerine patches to another resident. The facility lacked policies related to assessment of bruising and administration of transdermal patches.
Complaint Details
The visit was triggered by complaint investigations #71508, 70047, 71526, and 71518. The facility failed to identify and provide timely care for injuries of unknown origin for resident #1 and failed to accurately administer medication for resident #7.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to identify and promptly provide services for bruising and swelling of resident #1's chest and lower extremities. | SS=D |
| Failure to accurately administer nitroglycerine patches to resident #7. | SS=D |
Report Facts
Facility census: 83
Number of nitroglycerine patches found: 7
Number of times patch applied: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct Care Staff | Reported noticing a small red spot on resident #1's right knee prior to fracture discovery. |
| Staff J | Direct Care Staff | Interviewed regarding resident #1's transfer and inability to bear weight. |
| Staff K | Direct Care Staff | Notified of resident #1's fractured leg and swelling. |
| Staff B | Therapy Staff | Reported bruising on resident #1's knees to charge nurse. |
| Staff G | Therapy Staff | Observed and reported bruising on resident #1's knees and leg. |
| Nurse A | Licensed Nurse | Assessed resident #1's swollen leg and communicated with primary care physician. |
| Nurse D | Licensed Nurse | Followed up on resident #1's leg condition and arranged doctor's appointment. |
| Nurse L | Administrative Nurse | Discovered 7 old nitroglycerine patches on resident #7 and reviewed facility policies. |
Inspection Report
Follow-Up
Deficiencies: 2
Sep 25, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that the deficiencies previously cited under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.13(c) have been corrected as of 09/25/2013.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.13(c) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Sep 25, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies related to failure to report possible resident abuse and ensuring alleged perpetrators do not continue to provide care during investigations.
Findings
The facility was found deficient for failure to immediately report possible resident abuse and for allowing alleged perpetrators to continue working during investigations. Corrective actions include counseling employees, interviewing and assessing affected residents, mandatory staff training on abuse/neglect, and reporting concerns to the Quality Assurance committee.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation related to resident abuse concerns.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report possible resident abuse immediately and rough treatment to resident concerns. | D |
| Failure to ensure alleged perpetrator is not allowed to continue to work and provide care during abuse investigation. | E |
Report Facts
Complete Date for corrective action: Sep 25, 2013
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Aug 27, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#68494) regarding allegations of abuse involving residents at the facility.
Findings
The facility failed to thoroughly investigate and immediately report alleged abuse involving two residents. The facility also failed to protect residents from potential further abuse by allowing an alleged perpetrator to continue working during the investigation. Multiple staff interviews and witness statements revealed delays in reporting and inadequate immediate actions.
Complaint Details
The complaint investigation #68494 involved allegations of abuse for two residents. The facility failed to immediately report the allegations to the administrator and state officials as required by law. Investigations revealed delays in reporting and failure to suspend alleged staff promptly, risking resident safety.
Severity Breakdown
Level D: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and immediately report alleged abuse involving residents. | Level D |
| Failed to assure further potential abuse did not occur during the investigation process by allowing alleged perpetrator to continue working. | Level E |
Report Facts
Residents present: 82
Residents on hall 1: 17
Dates staff D worked: 8-8-13, 8-9-13, 8-12-13 (dates staff D worked during investigation period)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct Care Staff | Witnessed alleged abuse and delayed reporting |
| Staff D | Direct Care Staff | Alleged perpetrator involved in abuse incident |
| Staff F | Direct Care Staff | Witnessed and discussed alleged abuse |
| Staff E | Licensed Nursing Staff | Received delayed report of abuse and reported to Director of Nursing |
| Staff B | Administrative Nursing Staff | Investigated abuse, suspended staff D late, failed to immediately report to state |
| Staff A | Administrative Staff | Unaware of incident immediately, reported no concerns after investigation |
| Staff H | Direct Care Staff | Alleged verbally rough treatment of resident #2 |
| Staff I | Direct Care Staff | Reported staff H's hostile behavior |
| Staff J | Direct Care Staff | Reported staff H's hostile behavior |
| Staff G | Medical Records Staff | Informed Staff B about statements on DON's desk |
Inspection Report
Follow-Up
Deficiencies: 1
Feb 12, 2013
Visit Reason
This report documents a follow-up visit to verify correction of previously reported deficiencies at Kansas Christian Home.
Findings
The previously reported deficiency identified by regulation 26-40-302 was corrected as of the revisit date 2013-02-12.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-302 |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 12, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date 02/12/2013.
Report Facts
Deficiencies corrected: 10
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 1
Jan 14, 2013
Visit Reason
The visit was a health resurvey to assess compliance with nursing facility support system regulations, specifically regarding the wireless call light system.
Findings
The facility failed to have a wireless call light system that repeats unanswered calls within three minutes and sends the alert to other staff not originally designated to receive the call, potentially affecting all residents using call lights for assistance.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a wireless system that repeats unanswered calls within three minutes and sends alerts to other staff not originally designated to receive the call. | SS=E |
Report Facts
Facility census: 83
Inspection Report
Follow-Up
Deficiencies: 4
Oct 20, 2011
Visit Reason
This report documents a post-certification revisit to verify that previously identified deficiencies have been corrected as of the revisit date.
Findings
The revisit confirmed that all previously cited deficiencies under regulations 483.20(b)(1), 483.20(d), 483.25(l), and 483.70(f) were corrected by 10/20/2011.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(d) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.70(f) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 4
Sep 21, 2011
Visit Reason
The inspection was a health resurvey to assess compliance with comprehensive resident assessments and other regulatory requirements.
Findings
The facility failed to complete comprehensive assessments properly for all sampled residents, lacked documentation of assessment information locations, failed to maintain resident assessments for 15 months in active records, did not monitor effectiveness of certain medications, and failed to ensure proper function and monitoring of resident call light systems.
Severity Breakdown
SS=F: 2
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to complete all required components of comprehensive assessments for 11 of 11 residents sampled and failure to document location of assessment information in records. | SS=F |
| Failure to maintain all resident assessments completed within the previous 15 months in the resident's active record for 16 sampled residents. | SS=F |
| Failure to ensure drug regimen was free from unnecessary drugs due to lack of monitoring effectiveness of PRN medications and blood pressure medication. | SS=D |
| Failure to ensure the nurses' station was equipped to receive resident calls from rooms and bathrooms due to malfunctioning call light system and lack of routine monitoring. | SS=D |
Report Facts
Facility census: 86
Residents reviewed for unnecessary drugs: 10
Residents sampled for assessment review: 11
Residents sampled for MDS maintenance review: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Interviewed multiple times confirming lack of documentation and knowledge regarding comprehensive assessments and MDS processes. | |
| Administrative staff A | Reported facility maintained some records electronically and some on paper; confirmed nurses lacked access to MDS information. | |
| Maintenance staff E | Identified faulty call light switch and replaced it; reported no routine monthly checks of call lights. | |
| Maintenance staff F | Confirmed maintenance staff do not perform regular or preventive maintenance checks on call lights. | |
| Licensed nurse B | Interviewed regarding lack of knowledge of CAAS sections and documentation requirements. | |
| Licensed nurse G | Reported nursing staff did not perform routine checks of call lights. | |
| Administrative nursing staff G | Confirmed expectation for staff to monitor and record outcomes of PRN medications. |
Inspection Report
Plan of Correction
Deficiencies: 10
N040004 POC VHM511
Visit Reason
This document is a Plan of Correction submitted by Kansas Christian Home in response to deficiencies identified in a prior inspection.
Findings
The plan outlines corrective actions taken or to be taken for multiple deficiencies including resident rights education, abuse investigations, dignity and respect in care, communication improvements, medication management with black box warnings, dental care follow-up, infection control, and wireless call system improvements.
Severity Breakdown
D: 4
E: 4
F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Residents will be educated on their rights to access and how to contact the ombudsman services. | D |
| Investigation of residents' concerns of rough talking and treatment; employee terminated. | D |
| Staff educated to provide care with dignity and respect; dignity policy created. | D |
| Communication system developed to monitor and inform residents of plans addressing complaints. | D |
| Black Box warnings added to medications; AIMS testing completed for affected residents. | E |
| Dental appointments made for affected residents with follow-up scheduled. | D |
| Physicians faxed requesting dose reduction or risk vs. benefit statements for medication use. | E |
| System implemented for identifying organisms responsible for infections and proper disinfectant use. | F |
| QA meeting held addressing all concerns and survey results. | F |
| Wireless call system changed to repeat unanswered calls after 3 minutes to another staff. | E |
Report Facts
Corrective action completion date: Feb 12, 2013
Corrective action completion date: Jan 17, 2013
Corrective action completion date: Jan 14, 2013
Corrective action completion date: Jan 9, 2013
Corrective action completion date: Jan 18, 2013
Call unanswered repeat time: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Nachtigal | CEO/Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
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