Inspection Reports for
Smoky Hill Rehabilitation Center

The complaint investigations #KS00172328 and KS00172172 found that Resident 1 eloped from the facility on 06/06/22, exposing him to immediate jeopardy. The facility was informed of the immediate jeopardy situation on 06/09/22 and took corrective actions including increased monitoring and securing exits.

The facility failed to prevent R1 from eloping through an unalarmed back door and an unsecured gate, resulting in Immediate Jeopardy. R1 was found three blocks away unharmed. The facility implemented 15-minute checks, changed exit codes, secured gates with alternative locks, and conducted an audit of all residents at risk for wandering. The scope and severity of the deficiency was rated as 'D'.

The plan addresses the movement of Resident R1 to a secure locked unit, staff placement for monitoring, changes to exit door security, staff education on resident safety, and ongoing audits and reviews to ensure compliance and resident safety.

The plan addresses multiple deficiencies related to resident care including pain assessment, medication self-administration, transfer assistance, behavior management, injury prevention, bathing, dental services, nutrition, and risk management. The facility outlines corrective actions such as in-services, audits, care plan updates, monitoring, and education to ensure compliance and improve resident care.

The facility failed to employ a full-time certified dietary manager to plan and supervise meal preparation for the 55 residents, placing them at risk for inadequate nutrition.

The visit was triggered by complaint investigations KS00168527 and KS00168525.

The facility failed to assess residents for safe self-administration of medications and did not consistently provide bathing and linen changes as per care plans for multiple residents, placing them at risk for medication errors, impaired dignity, infection, and skin integrity issues.

The plan addresses deficiencies related to residents' ability to self-administer medications, proper changing of bed linens, and bathing of residents. Corrective actions include staff in-service training, audits by nursing leadership, and ongoing review in the facility's Quality Assurance Performance Improvement (QAPI) meetings.

An audit was performed to review the Treatment Admission Report (TAR) for missed treatments or documentation issues. The facility implemented education and monitoring measures to ensure compliance with wound care policies and procedures.

The findings represent the results of complaint investigations #165311 and #165348. The facility failed to comply with physician orders for wound care treatments for resident R1, substantiating the complaint.

The facility failed to provide necessary treatments and services to promote healing of pressure ulcers for one resident (R1) despite physician orders, resulting in prolonged wound healing and placing the resident at risk.

Complaint investigation #164011. The medication error was substantiated, placing the resident in immediate jeopardy.

The facility failed to correctly transcribe admission medication orders for one resident, resulting in the resident receiving Methotrexate daily instead of weekly as prescribed. This medication error caused the resident to develop a gastrointestinal bleed, be hospitalized, and subsequently die. The facility identified the error, conducted audits, and provided in-service education to nursing staff.

The Plan of Correction addresses past noncompliance issues identified under tags F0000 and F760-J, with corrective actions completed by 07/09/2021.

The visit was triggered by complaint investigations #160536 and #160726. The facility was found to have misappropriated narcotic medication, confirmed by missing Fentanyl patches and improper medication handling. The complaint was substantiated leading to staff suspension and termination.

The facility failed to ensure one resident was free from abuse when their pain medication, specifically Fentanyl patches, was misappropriated. The investigation revealed missing narcotic patches, improper logging and handling of controlled substances by staff, and subsequent police notification and staff termination.

The facility identified a missing pain medication for Resident R2 and implemented a new tracking system, staff education, and revised controlled substance count procedures to prevent recurrence. The plan includes weekly audits and integration into the Quality Assurance Performance Improvement program.

The complaint involved an unauthorized video posted on social media by a staff member showing Resident 1 in a vulnerable state. The immediate jeopardy was determined to be past non-compliance after the facility suspended and terminated the staff involved and re-educated all staff on abuse, neglect, exploitation, and cell phone/media policy.

The facility was found not to be in substantial compliance with 42 CFR 483.12 due to an immediate jeopardy situation involving abuse of Resident 1, which was determined to be past non-compliance after corrective actions were taken.

The complaint investigation revealed that CNA M posted a video of Resident 1 on social media showing the resident in a vulnerable state. CNA N saw the video but delayed reporting it to management. The facility failed to report the abuse allegation immediately as required by policy.

The facility failed to prevent an incident of abuse when a Certified Nurse Aide posted a video of a resident in a vulnerable state on social media, placing the resident at risk of humiliation. Additionally, the facility failed to ensure timely reporting of the abuse incident by staff. The facility terminated the responsible CNA and provided staff education on abuse and social media policies.

The plan addresses multiple deficiencies related to resident care, including ensuring residents have designated representatives or DPOAs, proper transportation policies, updated advance directives, resident inventory sheets, individualized care plans and activities, nutritional interventions, blood sugar management, dietary services oversight, and safe water/ice provision. Corrective actions include audits, staff in-services, ongoing monitoring, and integration into the facility's Quality Assurance Performance Improvement (QAPI) program.

The visit included complaint investigations #150773, #150846, #152051, #152166, and #154682.

The facility had multiple deficiencies including failure to provide resident rights representation, reasonable accommodations, advance directives, personal property documentation, individualized activities, nutritional interventions, social services, medication monitoring, qualified dietary staff, and infection prevention and control.

The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The complaint investigation found the facility was not in substantial compliance with 483.45 due to medication errors leading to immediate jeopardy for Resident 1. The immediate jeopardy began on 11/15/19 and was removed on 01/21/2020 after corrective actions including suspension of Licensed Nurse G and education of licensed nurses.

The facility failed to administer Resident 1's prescribed medications from 11/15/2019 through 01/19/2020, resulting in immediate jeopardy due to altered mental status, critical low thyroid levels, and hospitalization. The failure was linked to improper medication order documentation and verification during admission.

The Plan of Correction addresses past non-compliance issues identified under tags F0000 and F760-J, with corrective actions completed by 01/21/2020.

The facility acknowledged that Resident #1 no longer resides there and that care plan meeting notices were not consistently sent. Measures including audits, staff education, and monitoring were implemented to prevent recurrence.

The findings represent the results of complaint investigations #139862 and #141736. The facility failed to notify the representatives of residents #1 and #3 about care plan meetings, violating their rights to participate in care planning.

The facility failed to notify the representatives of two sampled residents (#1 and #3) about care plan meetings, denying them the right to participate in the planning process, which placed the residents at risk for inadequate care and unmet needs.

The plan addresses multiple deficiencies including baseline care plans, pressure ulcer prevention, nutritional supplements, medication disposal, and oversight of dietary services. Corrective actions include audits, staff education, monitoring, and ongoing quality assurance reviews.

The visit was triggered by complaint investigations #136279 and #137846.

The facility failed to develop baseline care plans with specific ADL directions for 2 sampled residents, failed to prevent and treat pressure ulcers for 1 resident, failed to provide nutritional support consistent with care plans for 2 residents, failed to maintain a system for returning unused medications, and failed to provide a certified dietary manager.

The revisit inspection found that all previously cited deficiencies have been corrected and no new noncompliance was identified. The facility is in compliance with all regulations surveyed.

The plan addresses multiple deficiencies including proper notification of Medicare non-coverage, investigation and reporting of resident-to-resident altercations, updating care plans for nutritional supplements, medication administration errors, expired medications, food handling procedures, and proper disinfection of glucose meters. Corrective actions include staff education, monitoring, audits, and integration into the facility's Quality Assurance Performance Improvement (QAPI) program.

The inspection included complaint investigations for allegations including failure to provide ABN notices, failure to report resident-to-resident altercation, and medication errors.

The facility had multiple deficiencies including failure to provide Advance Beneficiary Notices for skilled services, failure to report and investigate a resident-to-resident altercation, failure to revise care plans for nutritional supplements, failure to maintain acceptable nutritional status for several residents, failure to act on pharmacist recommendations for medication adjustments, medication errors including administration of another resident's medications, failure to date insulin pens and store medications properly, improper food handling practices, and failure to properly disinfect glucometers.

This Plan of Correction is related to the Smoky Hill complaint investigation dated 08/31/2017.

The plan addresses discharge procedures for residents, including review of discharge documentation, notifications to appropriate agencies, staff in-service training, and audits of discharge plans to ensure compliance and resident safety.

Complaint investigation #120132 focused on failure to comply with transfer/discharge notice requirements and discharge planning for Resident #1.

The facility failed to record reasons for discharge in the medical record, failed to notify the Office of the State Long-Term Care Ombudsman, failed to provide a 30-day discharge notice to a terminally ill resident receiving Hospice services, and failed to ensure the resident was discharged to a safe environment. The facility also failed to develop and implement an effective discharge plan and post-discharge plan of care for the resident.

The revisit confirmed that the previously cited deficiency related to regulation 483.45(f)(1) was corrected as of 06/22/2017. No other deficiencies or uncorrected issues were noted.

This plan of correction is in response to the Smoky Hill complaint investigation dated 06/19/2017.

The plan addresses medication errors related to medication patches, noting that Resident #1 no longer resides in the facility and Resident #2 was assessed with no adverse reactions. Staff were educated on medication error definitions and administration protocols, and new monitoring procedures were implemented to ensure compliance.

The survey found a 'D' level deficiency indicating 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, resulting in a finding of substantial compliance effective June 22, 2017.

The complaint investigation found substantiated medication errors involving improper management of Fentanyl patches leading to residents receiving twice the ordered narcotic dose.

The facility failed to ensure that medication error rates were below 5%, with two of three residents reviewed receiving medications incorrectly. Specifically, two residents had overlapping Fentanyl patches applied without removal of the previous patch, resulting in double dosing and risk of adverse effects.

The revisit report confirms that the previously cited deficiency with ID Prefix F0315 related to regulation 483.25(e)(1)-(3) was corrected as of 06/09/2017. No other deficiencies or uncorrected issues are noted.

The survey found the most serious deficiency to be a "D" level deficiency that constitutes no actual harm 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 June 9, 2017.

This Plan of Correction is related to a revised complaint inspection identified as Smoky Hill revised complaint 05302017.

The facility acknowledged the need to provide timely toileting for Resident #1 and reviewed the bowel and bladder program for appropriateness. Staff education and monitoring plans were established to ensure compliance and corrective action effectiveness.

The findings represent the results of complaint investigations #114840 and #115689. The facility failed to provide appropriate continence care for Resident #1, who was frequently incontinent of urine and was not toileted as care planned, leading to wet clothing and potential health risks.

The facility failed to provide appropriate treatment and services for one of three residents reviewed for incontinence, specifically Resident #1, who was frequently incontinent of urine and was not toileted in a timely manner, resulting in wet clothing and increased risk of embarrassment, infections, and skin breakdown.

The revisit confirmed that the deficiencies identified in the prior survey were corrected as of 06/16/2016, with corrections documented for specific regulation numbers.

This Plan of Correction is related to the Smoky Hill complaint investigation dated 06/14/2016.

The plan addresses deficiencies related to staff suspension pending investigation, staff education on responding to full code events, CPR and Basic Life Support policy training, and ensuring Certified Nursing Assistants receive required yearly education.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety related to F155, CFR 483.10(b)(4). Enforcement remedies including denial of payment for new admissions were imposed.

The complaint investigations revealed that staff failed to initiate CPR on Resident #1 who was a full code and found unresponsive without pulse or respirations, leading to immediate jeopardy. The facility also failed to provide required annual in-service education to some nurse aides.

The facility failed to initiate CPR for a full code resident who was found unresponsive and ultimately died, placing the resident in immediate jeopardy. Additionally, the facility failed to provide the required 12 hours of yearly education for 4 of the 34 nurse aides employed.

All previously cited deficiencies were corrected as of the revisit date, with each correction completed and documented accordingly.

The facility identified multiple deficiencies related to resident dignity and respect, housekeeping and maintenance, care planning for toileting, accident hazard prevention, medication labeling and storage, and infection control. Corrective actions include staff education, care plan updates, maintenance repairs, and ongoing monitoring integrated into the Quality Assurance Performance Improvement (QAPI) program.

The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.

The inspection included complaint investigations #100279, #99678 and #96776.

The facility failed to promote dignity and respect by removing dishes and cleaning dining tables while residents were still eating, failed to act on resident grievances about bedding changes, failed to maintain a sanitary and comfortable environment due to room damages, failed to develop comprehensive care plans for urinary incontinence, failed to assess bowel status and provide interventions, failed to provide appropriate urinary incontinence treatment, failed to maintain a safe environment by cleaning tables with disinfectant while residents were seated, failed to secure treatment carts and medication storage, failed to ensure proper labeling and storage of medications, and failed to maintain infection control by improper cleaning of resident bathrooms.

The survey found the most serious deficiencies at the facility to be at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

All previously cited deficiencies were corrected as of 01/29/2016, with no uncorrected deficiencies noted at the time of this revisit.

This Plan of Correction is in response to the Smokey Hill complaint dated 01/20/2016.

The plan addresses multiple deficiencies related to resident care, including notification of physician for changes in condition, abuse neglect exploitation policies, care plan updates for urinary status and weight loss, peri-care competency, infection control, and quality assurance monitoring. Substantial compliance was reported to be accomplished by January 29, 2016.

The facility was found not to be in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety from December 4, 2015 through January 15, 2016 related to F315, CFR 483.25(d). Enforcement remedies including denial of payment for new admissions were imposed.

The complaint investigations #95076 and #95570 included allegations of failure to notify physician of resident decline, abuse reporting failures, inadequate care plan revisions, infection control deficiencies, and nutritional neglect.

The facility failed to timely notify a physician of a resident's significant decline resulting in systemic infection and death, failed to promptly report and investigate an allegation of abuse, failed to revise care plans for urinary status and nutrition, failed to provide appropriate peri-care leading to UTIs, and failed to maintain an effective infection control program and quality assurance committee to monitor and address infection trends.

The report confirms that the previously cited deficiency with regulation 483.25(a)(3) was corrected as of 09/04/2015. No other deficiencies or uncorrected issues are noted.

The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective September 4, 2015.

The visit was complaint-related, involving investigations #89911, #89208, and #89864. The deficiency was substantiated as the facility failed to follow the resident's care plan for transfers.

The facility failed to provide one of three sampled residents, who was dependent on staff, with a safe and appropriate transfer method, creating a potential for injury. Staff transferred the resident by lifting under the arms instead of using the required gait belt or mechanical lift as per the care plan.

The report confirms that the previously cited deficiency with regulation 28-39-158(a) was corrected as of 05/15/2015. No other deficiencies or uncorrected issues are noted.

The report documents that all previously cited deficiencies were corrected by 05/15/2015, with no uncorrected deficiencies remaining at the time of the revisit.

The plan addresses multiple deficiencies including investigation of alleged abuse and neglect, promotion of resident dignity and respect, activities programming, social services, housekeeping and maintenance, accurate resident assessments, medication monitoring, care plan revisions, pressure ulcer prevention, infection control, hydration monitoring, dental services, and environmental safety. The facility commits to staff training, monitoring, and integration of corrective actions into the Quality Assurance Performance Improvement (QAPI) program.

The survey found the most serious deficiencies in the facility to be at 'F' level, resulting in enforcement remedies including a denial of payment for new Medicare admissions effective July 16, 2015, until substantial compliance is achieved or the provider agreement is terminated.

The visit was triggered by a complaint investigation #85797 related to abuse, neglect, mistreatment, and failure to report incidents.

The facility failed to thoroughly investigate and report falls with injury, maintain resident dignity and hygiene, provide individualized activities, ensure medically-related social services, maintain a sanitary environment, accurately assess residents, develop and revise care plans, provide necessary care and services, monitor medications with black box warnings, provide palatable food at proper temperatures, provide dental services, and maintain a safe environment.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.

The revisit report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 12/12/2014.

The survey found a 'D level deficiency' indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The revisit found the most serious deficiency in the facility to be a 'D' level deficiency. Based on the deficiencies cited, denial of payment for new Medicare/Medicaid admissions will be imposed effective January 23, 2015, and termination of the provider agreement is recommended for April 23, 2015.

The report documents that multiple deficiencies previously cited under regulations 483.10(b)(11), 483.25(a)(3), and 483.25(f)(2) were corrected as of 11/07/2014.

This Plan of Correction is linked to Complaint 120114, indicating the visit was complaint-related.

The plan addresses deficiencies related to improper resident transfer techniques involving resident #7, with corrective actions including staff training, use of a Broda chair, and ongoing monitoring of mechanical lift transfers.

The investigation was triggered by complaints #80988, #81180, and #81104. The complaint was substantiated as the facility failed to safely transfer Resident #7, causing bruising.

The facility failed to provide safe transfer techniques for one resident using a mechanical lift, resulting in extensive bruising. Staff used an unsafe method by tilting the wheelchair backwards during transfer, contrary to facility policy and training.

The survey found the most serious deficiency in the facility to be a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare admissions effective January 23, 2015, were recommended due to failure to achieve substantial compliance.

The inspection findings represent the results of complaint investigations #78773, #79053, #78239, #79461, #79458, #80044, #80245. The complaint involved failure to notify physician of significant resident changes, inadequate ADL care, and failure to evaluate psychosocial status.

The facility failed to promptly notify the physician of a significant change in Resident #4's psychosocial status prior to the resident leaving the facility. The facility also failed to provide adequate bathing services for dependent residents #2 and #6, and failed to evaluate Resident #4's behavior to maintain mental or psychosocial functioning.

The report confirms that the deficiency identified under regulation 26-40-301 (c)(3)(4)(5)(6) was corrected as of 04/16/2014.

The revisit confirmed that all previously reported deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.

The plan addresses multiple deficiencies including resident rights related to mail delivery, use of restraints, reporting of abuse and neglect, grievance handling, completion of resident assessments, medication administration, food service sanitation, pharmacist reporting of drug regimen irregularities, and facility maintenance such as parking lot repairs.

The visit was complaint-related as indicated by the Health Resurvey and complaint investigation #71712. Resident council minutes from April and May 2013 and March 2014 documented complaints about the rough, uneven asphalt surface with numerous potholes. Activity Staff A and Administrative Staff E verified the findings.

The facility failed to maintain a safe entryway and parking lot free of potholes and uneven rough surfaces, posing safety risks to residents, staff, and visitors. Resident council minutes documented complaints about the rough asphalt surface, and staff verified these environmental concerns.

The report confirms that the deficiencies previously cited under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h) were corrected by 12/06/2013.

The complaint investigation (#69073) found the facility did not thoroughly investigate the resident's injury fall and failed to provide adequate supervision, resulting in two unattended falls with serious injuries.

The facility failed to thoroughly investigate an accident resulting in injury for one resident and failed to provide adequate supervision to prevent two unattended falls in the dementia unit dining room, resulting in serious injuries including a head laceration, hip fracture, and brain hemorrhages.

The revisit report shows that deficiencies identified under regulations 483.25(k) and 483.60(a),(b) were corrected as of 09/06/2013.

The visit was a Non-Compliance Revisit and Complaint investigation #67054, 66910, and 67090.

The facility failed to provide proper respiratory care for one resident when the oxygen tank was empty, causing labored breathing and anxiety. Additionally, the facility failed to administer physician-ordered medications to a newly admitted resident on the day of admission.

This Plan of Correction is in response to a complaint investigation identified as Smoky Hill 061813 Complaint.

The plan addresses multiple deficiencies related to provision of medically related social services, comprehensive care plans, pain management, pressure ulcer prevention, and resident assessments. The facility outlines corrective actions including staff in-service, interdisciplinary team monitoring, policy reviews, and integration into the Quality Assurance Performance Improvement (QAPI) program.

The visit was triggered by complaint investigation #66205. The complaint was substantiated as the facility failed in multiple areas of resident care for Resident #2.

The facility failed to provide medically-related social services, develop a comprehensive care plan for comfort care, provide effective pain management, promote aggressive wound management, and maintain acceptable nutritional status for Resident #2, who was on comfort care and had a stage 4 pressure ulcer and significant weight loss.

All previously cited deficiencies listed on the CMS-2567 were corrected as of the revisit date, with corrections completed on 03/06/2013.

The Plan of Correction outlines multiple deficiencies related to resident care, staff training, documentation, facility maintenance, and compliance with policies. Corrective actions include staff in-services, audits, monitoring protocols, and facility repairs with specified completion dates.

The facility was found deficient in multiple areas including failure to notify legal representatives of changes, inadequate employee background checks, dignity concerns, housekeeping and maintenance issues, inaccurate resident assessments, failure to revise care plans, inadequate care and services for residents, improper medication management, nurse staffing posting errors, unsanitary food preparation, missing medication diagnosis, malfunctioning nurse call systems, and insufficient dining space in the memory care unit.

This Plan of Correction is related to a complaint investigation identified as Smoky Hill 111913 Complaint.

The facility acknowledged deficiencies involving alleged mistreatment, neglect, abuse, injuries of unknown origin, misappropriation of resident property, and inadequate supervision to prevent accidents. The plan outlines corrective actions including policy review, staff training, resident assessments, and ongoing monitoring through the Quality Assurance Performance Improvement (QAPI) program.

This Plan of Correction is in response to a complaint investigation at Smoky Hill Rehabilitation Center.

The plan addresses deficiencies related to respiratory care and medication administration, including staff in-service training, monitoring, and quality assurance measures to ensure proper treatment and adequate medication supplies.

This Plan of Correction is related to a complaint investigation identified by the event ID IKH711 and deficiency report 2567.

The facility addressed deficiencies related to safe transfer techniques for residents requiring assistance, including reviewing and correcting care plans, educating staff, and implementing observation protocols to ensure compliance.

This Plan of Correction is linked to a complaint investigation at Smoky Hill Rehabilitation Center.

The plan addresses deficiencies related to notification of changes in resident status, bathing schedules for dependent residents, and identification and intervention for residents with depression or psychosocial issues. Corrective actions include staff in-service training, monitoring compliance, and integration into the Quality Assurance Performance Improvement program.