Inspection Reports for
Medicalodges Kinsley

The complaint investigation involved an allegation that on 06/08/2025 at approximately 01:30 AM, CNA M verbally threatened Resident 1 with physical violence. The incident was witnessed by CNA O. The allegation was not reported to the nurse or administration until 06/11/2025, three days later. CNA M was terminated following the investigation. The facility's failure to timely report the abuse allowed CNA M to work three additional shifts.

The facility failed to ensure Resident 1 was free from verbal abuse and mistreatment by CNA M, who threatened the resident with physical violence. Additionally, the facility failed to report the allegation of abuse within the required timeframe, allowing CNA M to work additional shifts before termination. Staff education was inconsistently provided following the incident.

The plan details corrective actions including weekly psychosocial visits, suspension and termination of a CNA pending investigation, staff education on abuse recognition and reporting, resident interviews, emergency QAPI meetings, and law enforcement notification.

The facility failed to obtain timely supporting documentation for evidence of certification and criminal background checks for newly hired staff, as required by state regulations. The Administrator/Licensed Nurse confirmed missing and late documentation for several employees.

The plan addresses multiple deficiencies including proper issuance of Beneficiary Protection Notification forms, completion of significant change MDS assessments, skin condition assessments, pain assessments, medication monitoring, kitchen sanitation, and accurate reporting of staffing hours. The facility outlines education, monitoring, and auditing processes to maintain compliance.

The complaint investigation focused on Resident 74's pain management, which was found to be inadequate and led to immediate jeopardy. The facility failed to respond appropriately to pain complaints, communicate effectively with providers, and manage the resident's pain, contributing to distress and potential complications.

The facility was found not in substantial compliance with multiple deficiencies including failure to manage pain effectively for Resident 74, failure to complete significant change assessments for residents 11 and 19, failure to issue accurate Medicaid notices for Resident 16, failure to complete weekly skin assessments for Resident 19, failure to administer heart medication for Resident 16, unsanitary food storage and preparation practices, and failure to submit accurate staffing data to Payroll Based Journal.

The facility failed to conduct required annual functional capacity screenings and negotiated service agreement reviews for sampled residents. Additionally, the facility did not perform quarterly reviews of the emergency management plan with residents and staff, and the plan lacked procedures for natural gas leak emergencies.

The plan addresses deficiencies related to nebulizer equipment maintenance and staff education on BIPA posting and RN coverage, with corrective actions and monitoring plans described to achieve substantial compliance by 02/22/2023.

The visit was triggered by complaints identified as #KS00176439 and #KS00176011, involving respiratory care and staffing issues.

The facility failed to ensure necessary respiratory care for a resident requiring inhalation treatments, including improper cleaning and storage of nebulizer equipment, and lacked a respiratory care policy. Additionally, the facility failed to provide required registered nurse coverage for at least 8 hours a day, seven days a week, for five of the six months reviewed.

The report confirms that previously identified deficiencies related to regulations 26-41-104(d) and 26-41-207(b)(5-6)(c) were corrected and completed by 10/12/2022.

The facility failed to ensure disaster and emergency preparedness by not performing quarterly reviews of the emergency management plan with staff and residents, and not conducting an annual emergency drill including evacuation. Additionally, the facility did not comply with tuberculosis (TB) guidelines, as several employees lacked timely TB testing and questionnaires upon hire.

The complaint investigation KS00164373 focused on accounting and records of personal funds, specifically regarding quarterly statements, notification of SSI resource limit balances, and conveyance of funds upon resident death.

The facility failed to provide quarterly resident funds statements to one resident and/or their durable power of attorney (DPOA), failed to notify a resident and/or DPOA when funds reached within $200 of the SSI resource limit, and failed to convey remaining resident funds within 30 days of death for two residents.

The plan addresses deficiencies related to providing quarterly resident funds statements and notification requirements when resident funds approach the SSI resource limit, including conveyance of remaining funds after discharge. The facility outlines corrective actions including education, audits, and ongoing monitoring to achieve substantial compliance by 09/10/2021.

The plan addresses deficiencies related to food procurement, storage, preparation, and sanitary practices, as well as abuse, neglect, and exploitation training for staff. The facility has implemented staff education, weekly audits, and ongoing monitoring to ensure compliance.

The visit was triggered by a complaint investigation #157445. The complaint was substantiated as deficiencies were found related to food safety and staff training.

The facility failed to ensure dietary staff wore hairnets and properly date food items after opening, posing a risk to all residents. Additionally, the facility did not ensure all staff received annual Abuse, Neglect, and Exploitation (ANE) training as required.

The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-104(d) and 26-41-207(b)(5-6)(c) were corrected as of 12/16/2020.

The facility failed to ensure quarterly reviews of the emergency management plan with employees and residents, and failed to comply with tuberculosis guidelines by not completing TB questionnaires for all residents since 07/31/19.

The facility failed to inform and provide resident R16 the opportunity to make decisions regarding alternative treatment options, failed to ensure quarterly care plan meetings for R16 and/or the resident's representative, failed to have a system for residents to file grievances anonymously, failed to follow care plans for oxygen tubing changes for residents R2 and R10 and to utilize R16's communication book, failed to provide an environment free from accident hazards by leaving chemicals accessible to residents, failed to ensure RN coverage for at least 8 consecutive hours a day on certain dates, failed to prepare pureed diets according to recipes, and failed to properly date food items stored in the refrigerator.

The Plan of Correction outlines corrective actions for multiple deficiencies including resident rights, care plan meetings, safety concerns, outdated oxygen tubing, chemical storage, staffing coverage, and dietary food handling and storage.

The facility was found deficient in multiple areas including failure to post required notices accessible to residents, incomplete and untimely functional capacity screenings, incomplete negotiated service agreements, medication administration errors, lack of quarterly emergency preparedness reviews, and failure to comply with tuberculosis testing requirements for residents and staff.

The report indicates that all previously cited deficiencies identified by regulation numbers 483.13(b) and 483.13(c)(1)(i)-(iv) were corrected as of 10/17/2016.

Investigation of complaint KS00106192 involving allegations of physical and verbal abuse of resident #1 by Direct Care Staff C. Abuse was witnessed by another staff member and reported to nursing and administrative staff who failed to take appropriate action or report to the State survey agency. The alleged perpetrator continued working and providing care to other residents for up to two months, placing all residents in immediate jeopardy.

The facility failed to ensure resident #1 was free from physical and verbal abuse by Direct Care Staff C, who was witnessed abusing the resident and making derogatory statements. The facility also failed to immediately report the abuse, conduct a thorough investigation, protect all residents during the investigation, and submit investigation results timely. The alleged perpetrator continued to provide care to other residents for up to two months.

The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from July 31, 2016 through September 29, 2016. The facility was determined to have substandard quality of care.

Complaint investigation related to allegations of abuse and rough handling by staff; interviews and assessments found no further allegations or injuries; employee involved resigned; administrator counseled and educated on abuse reporting.

The facility addressed allegations of abuse and rough handling by staff, including resignation of involved employees, counseling and education of the administrator, resident interviews showing no further allegations, skin assessments with no injuries, and implementation of ongoing monitoring and reporting protocols.

The plan outlines corrective actions for multiple deficiencies including bed hold policies, significant change assessments, care plan updates, fall management, medication regimen reviews, immunization documentation, nurse staffing postings, refrigerator temperature monitoring, pharmacy recommendations follow-up, infection control program implementation, and quality assurance performance improvement.

The facility failed to inform a resident's responsible party about the bed hold policy, complete significant change MDS assessments timely, revise care plans for toileting and fall prevention, conduct root cause analysis for falls, monitor and manage unnecessary medications including psychotropics and insulin, maintain infection control program with proper infection trending, post nurse staffing data, and maintain safe food storage and serving temperatures.

The survey found the most serious deficiency to be at 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report confirms that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 05/15/2015.

The Plan of Correction details multiple corrective actions including audits, education, monitoring, and environmental safety improvements to address deficiencies related to resident assessments, catheter care, medication use, food storage, laundry equipment, and facility safety.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective May 15, 2015.

The facility failed to employ a full-time dietary supervisor who had successfully completed a certified dietary manager's training/education course, as the current dietary manager was still enrolled in the certification course and not yet certified.

The survey found the most serious deficiencies to be 'D' level deficiencies, isolated, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report confirms that the previously cited deficiency with ID prefix S0835 and regulation number 28-39-161 was corrected as of 01/20/2014.

The report confirms that all previously identified deficiencies related to specific regulations were corrected as of 12/31/2013.

The Plan of Correction details multiple corrective actions including cleaning and maintenance of facility areas, staff in-service education on procedures such as pain assessment and sharps disposal, monitoring of resident assessments and care plans, and ongoing quality assurance oversight to prevent recurrence of deficiencies.

The facility was found deficient in multiple areas including failure to maintain sanitary conditions, incomplete comprehensive assessments, inadequate pain assessment and management, unsafe environment hazards, failure to prevent falls, improper medication monitoring, failure to report medication irregularities, improper disposal of sharps, and failure to maintain food storage sanitation.

The facility failed to complete a required assessment before a resident began self-administration of medications, failed to securely store medications accessible only to the resident and authorized staff, failed to maintain sanitary food storage and preparation conditions, and failed to ensure proper laundering and handling of linens by not monitoring laundry water temperatures daily.

The report shows that all previously identified deficiencies were corrected by the revisit date of 10/05/2012, with corrections documented for multiple regulatory requirements.

The facility was found deficient in developing a written negotiated service agreement reflecting residents' service needs, ensuring accessibility of the most recent survey report to residents and visitors, and maintaining sanitary food preparation conditions, specifically failing to clean the kitchen exhaust hood adequately.

The Plan of Correction outlines specific corrective actions to address multiple deficiencies including medication management, accessibility of survey results, cleanliness and maintenance of equipment and facility areas, and compliance with pharmacy review protocols. Responsibilities for ongoing compliance are assigned to various staff members including the Director of Nursing, Environmental Services Supervisor, and Facility Administrator.

The Plan of Correction details specific actions including assessment of resident #1 for medication self-administration, securing medications with a lock, cleaning and maintenance schedules for equipment, and staff training on laundry water temperature monitoring to prevent recurrence of cited deficiencies.