5 Reports
Inspection Report — Jul 17, 2025
Complaint Investigation CMS
Date: Jul 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of medications involving four residents.
Complaint Details
The complaint investigation was substantiated with evidence of medication diversion by a Certified Medication Aide. The facility conducted drug testing, notified police, and terminated the implicated staff member.
Findings
The facility failed to ensure four residents remained free from misappropriation of medications. The investigation revealed tampering with narcotic medication bubble packs, missing tablets replaced with other medications, and video evidence implicating a Certified Medication Aide who was subsequently terminated.
Deficiencies (1)
F 0602: Protect each resident from the wrongful use of the resident's belongings or money. The facility failed to prevent misappropriation of medications for four residents, involving tampered narcotic medication bubble packs and missing tablets replaced with other medications.
Report Facts
Residents affected: 4
Missing oxycodone tablets for R1: 8
Missing oxycodone tablets for R2: 21
Missing fludrocortisone tablets for R3: 16
Missing fludrocortisone tablets for R4: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Named as the staff member involved in medication diversion and terminated following investigation |
| LN G | Licensed Nurse | Noted tampering during narcotic count and participated in investigation |
| LN H | Licensed Nurse | Noted tampering during narcotic count and participated in investigation |
| Administrative Staff A | Conducted investigation and provided statements regarding the incident | |
| Administrative Nurse D | Administrative Nurse | Participated in investigation and provided statements |
| Administrative Nurse E | Administrative Nurse | Participated in investigation and provided statements |
Inspection Report — Jul 2, 2024
Complaint Investigation CMS
Date: Jul 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report an allegation of abuse and an injury of unknown origin for Resident 1 to the State Agency as required.
Complaint Details
The complaint involved an allegation of abuse and an injury of unknown origin for Resident 1. The facility's investigation did not find evidence of abuse but failed to report the allegation and injury to the State Agency as required. The allegation was unsubstantiated but the reporting failure was cited.
Findings
The facility failed to report suspected abuse and an injury of unknown origin for Resident 1 to the State Agency. The investigation concluded the bruising was related to pressure from leaning on a shower chair combined with fragile skin and blood thinner use, but the facility did not report the allegation as required, placing the resident at risk.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to proper authorities. This failure placed Resident 1 at risk for unidentified and ongoing abuse.
Report Facts
Bruise size: 7.5
Bruise size: 9
Bruise width: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Provided witness statement about bruises and staff behavior |
| CNA N | Certified Nurse Aide | Alleged to have been rough with Resident 1 during transfers; suspended pending investigation |
| LN G | Licensed Nurse | Assessed bruising and provided statements regarding investigation and reporting |
| Administrative Staff A | Received report from hospice nurse, conducted investigation, and stated facility did not report abuse to State Agency | |
| CNA Q | Certified Nurse Aide | Reported new bruising or injuries of unknown origin to nurse immediately |
| Administrative Nurse D | Described facility reporting procedures and investigation process | |
| CNA O | Certified Nurse Aide | Assisted Resident 1 in shower chair and described positioning |
| CNA P | Certified Nurse Aide | Assisted Resident 1 in shower chair and described positioning |
Inspection Report — Mar 20, 2024
Routine CMS
Date: Mar 20, 2024
Visit Reason
Routine inspection of Sabetha Manor nursing home to assess compliance with regulatory requirements including resident transfer notifications, staffing, dietary services, infection prevention, and quality assurance.
Findings
The facility failed to provide timely written transfer and bed hold notices to a resident and her representative, lacked required RN coverage and a full-time Director of Nursing, failed to employ a certified dietary manager, did not ensure proper food temperature checks and food safety, submitted inaccurate staffing data to CMS, lacked required Quality Assurance committee members, and did not employ a qualified Infection Preventionist.
Deficiencies (9)
F 0623: The facility failed to provide timely written notice to Resident 14 or her representative and the Long-Term Care Ombudsman regarding her transfer to the hospital, risking uninformed care choices.
F 0625: The facility failed to provide Resident 14 or her representative written notice of the facility's bed hold policy upon transfer to the hospital, risking the resident's ability to return.
F 0727: The facility failed to provide RN coverage eight consecutive hours daily and failed to employ a full-time Director of Nursing, risking decreased quality of care.
F 0801: The facility failed to employ a full-time certified dietary manager for 25 residents receiving meals, risking inadequate nutrition.
F 0804: The facility failed to check and record temperatures of pureed and regular breakfast foods before serving, risking foodborne illness and impaired palatability.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including storing unlabeled, undated, expired food and poor kitchen maintenance, risking foodborne illness.
F 0851: The facility failed to submit complete and accurate direct care staffing information to CMS, risking unidentified and ongoing inadequate nurse staffing.
F 0868: The facility failed to have required members, including a Director of Nursing and Infection Preventionist, attend Quality Assurance and Performance Improvement meetings quarterly, risking decreased quality of care.
F 0882: The facility failed to employ a designated Infection Preventionist with required certification, placing residents at increased risk for infections.
Report Facts
Sample size: 12
Dates without RN coverage: 12
Expired food items: 15
PBJ missing coverage dates: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service X | Named in failure to provide transfer and bed hold notices | |
| Licensed Nurse H | Licensed Nurse | Named in failure to provide transfer and bed hold notices |
| Dietary Staff BB | Dietary Manager | Named in failure to employ certified dietary manager and food temperature checks |
| Administrative Staff A | Verified lack of DON, staffing issues, and QAPI attendance | |
| Consultant Nurse GG | Nurse Consultant | Named in PBJ reporting and infection preventionist absence |
Inspection Report — Nov 15, 2022
Annual Inspection CMS
Date: Nov 15, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to staffing and food safety in the facility's dietary services.
Findings
The facility failed to employ a full-time certified dietary manager and failed to ensure staff wore proper hair coverings in the kitchen, placing residents at risk for inadequate nutrition and food borne illness.
Deficiencies (2)
F 0801: The facility failed to employ a full-time certified dietary manager to plan and supervise meal preparation for 26 residents, risking inadequate nutrition.
F 0812: The facility failed to ensure staff wore hair coverings in the kitchen, risking food borne illness for 26 residents.
Report Facts
Residents present: 26
Sample residents reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff (DS) BB | Observed preparing meals and noted as not certified dietary manager | |
| Administrative Staff A | Verified dietary manager certification status and hair covering expectations |
Inspection Report — Jun 9, 2021
Annual Inspection CMS
Date: Jun 9, 2021
Visit Reason
Annual inspection of Sabetha Manor nursing home to assess compliance with healthcare regulations, including medication management, communication facilitation, and laboratory testing.
Findings
The facility failed to facilitate effective communication for a resident with dementia, ensure timely and complete laboratory testing for multiple residents, properly monitor and report blood sugar levels outside physician parameters, and correctly store and date medications and biologicals. These deficiencies posed risks of unmet resident needs, inadequate treatment, and potential medication side effects.
Deficiencies (5)
F0676: The facility failed to facilitate effective communication between Resident 10 and staff, risking unmet needs and impaired psychosocial well-being.
F0756: The facility failed to ensure the Consultant Pharmacist identified and reported missing physician ordered laboratory tests for Residents 6, 8, 18, and 5, risking inadequate treatment and side effects.
F0757: The facility failed to identify blood sugar levels outside physician ordered parameters for Resident 18 and failed to ensure physician ordered blood laboratory tests were obtained for Residents 18, 5, 8, and 6.
F0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions prior to continuing psychotropic medications for Resident 5, risking unnecessary medication use.
F0761: The facility failed to properly store and date one tuberculin vial, three medicated eye drop bottles, and five medicated inhalers, risking ineffective treatment and physical complications.
Report Facts
Residents sampled: 11
Blood sugar readings outside parameters: 16
Missed lab draws: 4
Medication days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided information on missing lab tests, performance improvement plan, and medication storage policies. |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding communication board use and blood sugar monitoring for Resident 10 and 18. |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding laboratory draws and blood sugar monitoring procedures. |
| Certified Nurse Aide M | Certified Nurse Aide | Observed assisting Resident 10 and interviewed about communication methods. |
| Certified Nurse Aide N | Certified Nurse Aide | Observed assisting Resident 10 during transfer. |
| Dietary Manager BB | Dietary Manager | Interviewed about Resident 10's communication. |
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