Inspection Reports for
Via Christi Village Pittsburg Ks LLC

The facility failed to provide required care plan meetings for several residents, did not complete comprehensive care plans including instructions for personal equipment, failed to properly position residents in wheelchairs, did not perform adequate wound care hand hygiene, failed to monitor dialysis assessments, administered medication outside physician parameters, and did not ensure clean environment and equipment.

The plan addresses multiple deficiencies related to resident care plans, use of personal humidifiers, wheelchair foot rests, personal hygiene assistance, dialysis communication, medication parameter monitoring, antipsychotic medication assessments, wound care management, toilet riser safety, and privacy curtain cleanliness. Each deficiency was followed by assessments showing no adverse effects and corrective actions including staff re-education, policy reviews, and ongoing audits.

Investigation of complaint #189939 regarding failure to provide care plan meetings and other care deficiencies.

The facility failed to provide required care plan meetings for several residents, did not complete comprehensive care plans for some residents, failed to ensure proper grooming and hygiene, did not properly position residents in wheelchairs, failed to clean and maintain equipment including a personal humidifier, and did not follow medication administration parameters. Environmental concerns included soiled privacy curtains and unsafe resident equipment.

The complaint investigation substantiated that the facility failed to protect Resident 1 from neglect on 11/27/23 when staff left the resident on the floor for four hours without reporting. The resident sustained a left hip fracture requiring surgery. Immediate jeopardy was identified as of 11/27/23 at 12:45 PM.

The facility failed to prevent staff neglect of Resident 1, who was found on the floor with a left hip fracture after staff administered medications while the resident remained on the floor and failed to report the incident. The resident was left unattended for four hours before being discovered and transported to the hospital for surgical repair.

The findings represent the results of complaint investigation #KS00186159 and KS00186315.

The facility failed to prevent a medication error when a licensed nurse administered an as needed oxycodone dose and did not document it, resulting in a resident receiving two doses of oxycodone two hours apart, contrary to physician orders requiring a six-hour interval between doses.

The facility failed to prevent a medication error when a licensed nurse administered an as needed oxycodone dose without documenting it, resulting in a resident receiving two doses of oxycodone two hours apart, contrary to physician orders.

The facility identified issues with the administration and documentation of PRN controlled medications. Corrective actions include resident assessments, staff re-education, policy review, and ongoing audits to ensure compliance.

The inspection was triggered by complaint #176351.

The facility failed to inform resident R102 orally and in writing of the current rate for the level of care and services. The facility also failed to ensure the Negotiated Service Agreement for resident R104 identified who was responsible for administration and management of selected medications that R104 self-administered.

The facility identified a deficiency related to expired code status documentation for resident #1, who expired on 12/27/22. The facility has implemented corrective actions including staff education, routine reviews of code status, and monthly mock code drills to ensure compliance and prevent recurrence.

The complaint investigation #KS 177081 substantiated that the facility did not follow the resident's advance directives regarding CPR, resulting in CPR being performed contrary to the resident's DNR order.

The facility failed to honor a resident's Do Not Resuscitate (DNR) order when staff initiated CPR despite the resident having a current DNR in the medical record. Staff were unaware of the resident's updated code status, leading to inappropriate CPR administration.

The Plan of Correction outlines corrective actions for multiple deficiencies related to resident care, medication management, activity programming, food storage, and safety practices. The facility describes measures to prevent recurrence, including staff re-education, policy reviews, interdisciplinary team monitoring, and ongoing quality assurance oversight.

The facility was found deficient in multiple areas including failure to maintain resident dignity during care, inadequate wheelchair safety measures, incomplete care plans for wandering residents, insufficient activity programming, lack of range of motion services, failure to prevent falls, improper monitoring of elopement devices, inadequate dementia care interventions, failure to identify inappropriate medication use, failure to discard expired medications, and unsanitary food storage conditions.

The inspection was triggered by complaints identified as #KS00176330, KS00175970, and KS00174757.

The facility was found deficient in multiple areas including resident dignity and privacy, reasonable accommodations, care plan revisions, meaningful activities, range of motion services, accident prevention, dementia care, drug regimen review, psychotropic medication use, medication labeling and storage, and food safety.

The facility acknowledged deficiencies related to resident care plans and skin interventions. The plan outlines corrective actions including review and update of care plans, re-education of licensed nurses, and ongoing monitoring through clinical huddles and Quality Assurance Committee meetings.

The complaint investigation #165260 was substantiated with findings that the facility did not prevent further bruising to Resident 1 after the initial injury was reported and documented.

The facility failed to implement an intervention to prevent further bruising to Resident 1 after a large bruise was noted on her upper extremity caused by the bed's assistive rail. Multiple staff interviews and record reviews confirmed the lack of new interventions to prevent additional injury.

The plan outlines corrective actions for multiple residents related to fall interventions, skin interventions, nutrition and weight loss management, and laundry cycle compliance. The facility commits to re-education, monitoring, and ongoing Quality Assurance Committee reviews to ensure sustained compliance.

The facility failed to timely review and revise care plans for residents after falls and skin tears, failed to implement adequate fall prevention interventions, failed to timely identify and address significant weight loss in a resident, and failed to ensure proper laundering of blood-soiled linens to prevent infection.

The inspection was triggered by complaint investigations #152137, #160166, and #162242.

The facility failed to review and revise care plans timely for residents after falls and skin tears, failed to implement adequate fall prevention interventions, failed to maintain nutritional status for a resident with weight loss, and failed to ensure sanitary laundering of blood-soiled linens to prevent infection.

The COVID-19 survey was deficiency free, indicating no deficiencies were found during the inspection.

The facility was found to be deficiency free in the COVID survey conducted on 04/22/2020.

The plan addresses a deficiency related to transportation safety for resident #01, including corrective actions such as re-education of drivers and ongoing competency monitoring.

This report is based on complaint investigation #150063. The complaint was substantiated as the facility failed to prevent the resident's wheelchair from coming loose during transport, resulting in injury.

The facility failed to ensure the safety of one resident during transport when her wheelchair rolled forward, causing a large hematoma, open area, and bruising on her leg. The investigation found that the wheelchair was not properly secured and the facility lacked a policy for securing residents in the van.

The plan addresses multiple deficiencies related to resident rights, weight loss monitoring, environmental maintenance, care plan updates, medication administration, infection control, and kitchen sanitation. The facility outlines corrective actions, staff re-education, routine monitoring, and reporting to the Quality Assurance/Performance Improvement (QAPI) committee over a 3-month period.

Complaint investigations #142344 and #143675 triggered this health resurvey.

The facility had multiple deficiencies including failure to respect resident rights, failure to notify physicians of significant weight loss, unsafe and unsanitary environment conditions, incomplete and untimely care planning and assessments, failure to provide appropriate respiratory and medication care, failure to monitor and intervene for weight changes, failure to prevent falls, and failure to maintain safe and sanitary food and medication storage.

The plan addresses medication administration deficiencies, including missed medications and order entry errors, and outlines corrective actions such as staff re-education, monitoring, and reporting procedures to ensure compliance.

The inspection was triggered by complaint investigations #139540, #139687, and #141147. The complaints were substantiated as the facility failed to administer medications as ordered, resulting in significant medication errors and contributing to a resident's death.

The facility failed to administer medications as ordered by the physician for 2 of 3 residents reviewed, resulting in significant medication errors. One resident did not receive Xarelto and Cardizem as ordered for 2 days and subsequently died. Another resident failed to receive Atropine eye drops as ordered following an eye injury.

The facility acknowledged deficiencies related to fall prevention care plans and interventions. The plan outlines steps to review and update resident care plans, re-educate staff, and monitor compliance through quality assurance processes.

The findings represent the results of complaint investigations #137855, #138300, and #137884.

The facility failed to ensure that one resident wore the planned non-slip socks in bed, resulting in a fall and a fractured left elbow. The resident was not wearing non-skid socks or footwear at the time of the fall, despite care plan instructions.

The inspection was triggered by complaint investigations # KS00134698 and KS00134677.

The facility failed to provide individualized activity programs for 4 of 6 residents reviewed, and failed to provide adequate care to promote healing and prevent pressure ulcers for 4 of 4 residents reviewed. Additionally, the facility did not maintain sufficient nursing staff to meet residents' physical, mental, and psychosocial needs.

The survey found the most serious deficiency to be a level 'E' deficiency indicating no actual harm but 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 December 14, 2018.

The plan addresses deficiencies related to resident activity assessments, skin integrity evaluations, wound care, and staffing patterns. Corrective actions include updating care plans, re-educating staff, routine reviews, and monitoring through Quality Assurance/Performance Improvement (QAPI) meetings.

The plan addresses multiple deficiencies including wheelchair and assistive device safety, grievance follow-up, abuse reporting, care plan updates, medication administration, infection control, environmental cleanliness, pest control, and staffing ratios. The facility outlines corrective actions, staff re-education, monitoring, and ongoing Quality Assurance/Performance Improvement (QAPI) reviews.

The survey found a most serious deficiency at level "F", 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 reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-11-07.

The complaint investigation included multiple allegations of neglect, failure to provide reasonable accommodations, failure to report incidents, failure to provide adequate staffing and supervision, medication errors, infection control deficiencies, and pest control issues.

The facility failed to provide reasonable accommodations for resident needs, failed to respond to grievances timely, failed to report alleged violations timely, failed to complete timely comprehensive and significant change assessments, failed to revise care plans based on changing needs, failed to ensure adequate supervision and assistive devices to prevent falls, failed to provide sufficient nursing staff, failed to administer scheduled medications, failed to identify and act on medication irregularities, failed to ensure psychotropic medications were used appropriately, failed to label and store medications properly, failed to maintain sanitary food preparation and storage, failed to dispose of garbage properly, failed to maintain an effective infection control program, and failed to maintain an effective pest control program.

The facility identified issues related to safe transfer practices for residents requiring assistance. The plan includes re-evaluation of transfer status, staff re-education, audits of transfer processes, and ongoing Quality Assurance Committee review.

The investigation was triggered by complaint #0132658. The complaint was substantiated as the facility failed to provide a safe transfer, leading to a resident injury.

The facility failed to provide a safe transfer for one paraplegic resident, resulting in the resident's left leg/foot being bent under the wheelchair and causing a fractured hip. The resident required extensive assistance for transfers and the staff did not properly control the affected leg during transfer.

The facility identified deficiencies related to individualized care plans and behavior management. The plan outlines corrective actions including re-education of staff, monitoring of care plans and behaviors, and ongoing review by the Quality Assurance Committee.

Complaint investigation #KS00130178 focused on care plan timing, revision, and behavioral health services for one resident with severe cognitive impairment and behavioral issues. The complaint was substantiated based on findings of inadequate care plan revision and lack of behavioral health treatment.

The facility failed to review and revise the care plan for one resident with severe cognitive impairment and behavioral issues, resulting in inconsistent care and lack of individualized interventions. The resident exhibited uncontrolled behaviors, lacked psychosocial therapy, and the facility did not provide adequate behavioral health services or psychiatric interventions despite frequent disruptive behaviors impacting other residents.

The survey found a 'D' level deficiency indicating no actual harm but 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 August 1, 2018.

The plan addresses issues including notification of resident representatives after incidents, staffing adequacy and call light response, and medication administration procedures, particularly related to Lasix orders and weight monitoring.

The facility was found to have deficiencies regarding the verification and documentation of physician orders to crush medications for residents with dysphagia. The plan outlines corrective actions including re-education of staff and monitoring of physician orders and medication administration records.

The inspection was triggered by complaint investigations #129818, #129831, and #129960. The complaints involved failure to notify family of a resident's injury, inadequate staffing, and medication errors. The findings substantiated these complaints.

The facility failed to notify the responsible party timely after a resident's fall and injury requiring emergency treatment. Staffing was inadequate to meet resident care needs, causing delays in assistance. The facility also failed to administer a prescribed medication (Lasix) for three consecutive days, resulting in a resident's exacerbation of congestive heart failure and emergency room visit.

The findings represent the results of complaint investigations #121567, #124285, and #122367.

The facility failed to administer medications as ordered by the physician for one resident out of three sampled. Specifically, medications were crushed and administered without a physician's order to do so, contrary to facility policy and physician instructions.

The plan outlines corrective actions related to code status documentation, notification of reportable events, and bathing and oral care practices. Education and audits were implemented to ensure compliance and quality assurance.

The investigation was triggered by complaints #121105 and 121768 concerning failure to initiate CPR on a resident without a DNR order and inadequate care. The facility was found to have immediate jeopardy related to CPR initiation and delayed reporting to the state agency.

The facility failed to initiate CPR for a resident without a DNR order whose heart stopped, failed to report the incident timely, and did not document advance directives properly. Additionally, the facility failed to provide adequate oral care and bathing to dependent residents.

This Plan of Correction is in response to a complaint investigation at Via Christi Pittsburg dated June 30, 2017.

The facility identified deficiencies related to MDS quarterly assessments, inaccurate MDS data, care plan revisions, urinary incontinence management, and accident reviews. The Plan of Correction outlines corrective actions including audits, interdisciplinary team reviews, staff re-education, and ongoing monitoring to achieve substantial compliance by mid to late July 2017.

The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but 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 credible allegation of compliance and evidence of correction.

The inspection was triggered by complaint investigations #116151, #116996, and #116443 focusing on resident assessments, care planning, urinary continence, and fall prevention.

The facility failed to complete timely and accurate quarterly assessments, failed to develop and revise individualized care plans including toileting programs and fall prevention interventions, and failed to provide appropriate treatment for urinary incontinence and fall risk management for multiple residents. Several falls were not properly investigated or followed up with appropriate interventions.

The plan addresses deficiencies related to diet supplement orders, medication orders without adequate indications or monitoring, and pharmacy review processes. The facility outlines corrective actions including staff re-education, updated care plans, monitoring systems, and ongoing audits to ensure compliance.

All deficiencies previously cited in the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date. Each deficiency is identified by regulation number and marked as completed.

The facility failed to ensure residents received fortified foods as ordered and follow-up on dietitian recommendations. The facility also failed to ensure necessary medications with adequate monitoring, including inappropriate medication diagnoses and lack of blood glucose monitoring for insulin. The quality assurance committee was ineffective in addressing these deficiencies.

The report shows that the previously cited deficiency under regulation 26-41-206 (e)(1) was corrected as of the revisit date.

Complaint investigations included failure to notify residents of Medicare non-coverage, medication errors, inadequate pain management, pressure ulcers, weight loss monitoring, hydration, medication monitoring, falls, infection control, and staffing concerns.

The facility had multiple deficiencies including failure to timely notify residents of Medicare non-coverage, failure to notify physicians of significant weight loss, failure to report medication errors, inadequate pain management, failure to prevent pressure ulcers, insufficient staffing, unsanitary food storage and preparation, medication administration errors, incomplete medication monitoring, and inadequate infection control surveillance.

The survey found serious deficiencies at a level of actual harm but not immediate jeopardy, specifically citing noncompliance with F314 related to pressure ulcers. Due to repeated noncompliance, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.

The facility identified multiple areas requiring improvement including timely notification of Medicare Non-coverage, weight monitoring and reporting, medication administration accuracy, care plan participation, pain management, skin integrity, fall risk, hydration, medication review, infection control, maintenance, staffing, and quality assurance processes. Corrective actions and staff re-education plans are detailed for each deficiency.

The facility failed to store, prepare, and serve food under sanitary conditions. Observations included undated and unlabeled food items, buildup of dirt and debris in kitchen areas, and failure to ensure food products did not exceed expiration dates.

All deficiencies previously cited under various regulations were corrected as of the revisit date.

The inspection was triggered by complaint investigation #107534 concerning resident elopement risks, inadequate care planning, insufficient supervision, and staffing shortages.

The facility failed to accurately assess residents' wandering behaviors and elopement risks, develop comprehensive care plans for at-risk residents, ensure adequate supervision and assistive devices to prevent elopement, and maintain sufficient staffing levels to provide necessary care and supervision.

This Plan of Correction addresses deficiencies cited during a complaint investigation survey conducted on November 15, 2016, at Via Christi Village Pittsburg.

The facility identified deficiencies related to inaccurate coding of MDS assessments, incomplete comprehensive care plans, insufficient supervision to prevent elopement, and staffing concerns. The plan outlines corrective actions including staff retraining, audits, policy reviews, and enhanced monitoring to ensure compliance and resident safety.

The survey found a 'D' level deficiency indicating no actual harm but 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 credible allegation of compliance and evidence of correction.

This Plan of Correction is in response to a complaint investigation linked to complaint ID 10102016.

The facility identified deficiencies related to assessment accuracy, development of comprehensive care plans, maintenance and improvement of range of motion, and ensuring residents are free from accident hazards. The plan outlines corrective actions including audits, care plan revisions, staff education, and ongoing monitoring.

The inspection was triggered by multiple complaint investigations (#105195, #96723, #103569, #103608, #103558, #103628, #103971, and #97965).

The facility failed to complete accurate comprehensive assessments, develop individualized comprehensive care plans, provide necessary restorative services, and ensure safe transfers for residents. Specific deficiencies included inaccurate MDS coding, incomplete care plans, lack of restorative services, and unsafe use of mechanical lifts.

The survey found the most serious deficiencies 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 to address these deficiencies.

This Plan of Correction is related to a complaint investigation at Via Christi Village Pittsburg.

The plan addresses issues related to care plans and summaries for resident #1, focusing on updating and reviewing care plans to reflect current weight bearing status and ensuring proper supervision and use of care summaries by clinical staff.

The findings represent the results of complaint investigations #95513 and #96186. The complaint was substantiated as the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with weight bearing restrictions.

The facility failed to transfer and ambulate a resident with physician-ordered toe touch weight bearing restrictions safely, resulting in displacement of a femur fracture that required surgical repair. The resident care summary assessment lacked accurate weight bearing restrictions, leading to improper care by staff.

The survey found the most serious deficiency in the facility to be a "G" level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective May 1, 2016, until substantial compliance is achieved or the provider agreement is terminated.

The facility identified multiple deficiencies related to resident care plans, housekeeping and maintenance, infection control, medication storage, nursing staffing, and documentation. The Plan of Correction outlines corrective actions, staff education, monitoring, and accountability measures to address these issues.

The survey found the most serious deficiencies to be 'F' level, 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 based on the credible allegation of compliance.

The visit included a complaint investigation triggered by allegations related to resident grievances, staffing shortages, care deficiencies, and infection control issues. The complaints were substantiated as evidenced by multiple deficiencies cited.

The facility failed to act on resident grievances, maintain housekeeping and maintenance standards, revise care plans for urinary incontinence, provide necessary care for pressure ulcers, ensure adequate nursing staff, maintain infection control, secure narcotics, and maintain accurate clinical records.

The report confirms that the deficiencies previously cited under regulations 483.13(b), 483.13(c)(1)(i), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), and 483.20(d)(3), 483.10(k)(2) were corrected by the dates indicated in July 2015.

The survey found the facility was not in substantial compliance and constituted immediate jeopardy to resident health or safety from April 27, 2015 through June 18, 2015. Enforcement remedies including denial of payment for new admissions were recommended.

The complaint investigation involved allegations that resident #03 sexually abused two female residents (#7 and #8) and displayed inappropriate sexual and aggressive behaviors. The facility failed to investigate and report these incidents timely and failed to protect the residents, placing them in immediate jeopardy.

The facility failed to protect female residents from sexual abuse by a cognitively impaired resident and failed to thoroughly investigate and report the incidents. The facility also failed to revise the care plan to address the resident's inappropriate sexual and aggressive behaviors. Immediate jeopardy was identified and later abated with 1:1 supervision and staff education.

This plan of correction responds to a complaint investigation involving allegations of abuse and neglect related to resident #3's inappropriate sexual behaviors and the facility's response.

The facility addressed allegations of abuse and neglect involving resident #3, including inappropriate sexual behaviors requiring 1:1 supervision and transfer for psychological evaluation. The plan outlines staff training, monitoring, care plan updates, grievance process revisions, and ongoing quality assurance reviews to prevent recurrence.

The survey found the most serious deficiencies to be 'F' level, 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 is not achieved.

The facility was found to have deficiencies related to food storage, preparation, and sanitation in the Assisted Living kitchenette. The plan outlines corrective actions including revised cleaning schedules and staff education to ensure compliance.

The report confirms that the deficiency identified by regulation 28-39-255 with ID prefix S3400 was corrected as of 07/18/2014. No other deficiencies are listed.

The facility identified multiple deficiencies related to individualized care plans for fall risk, admission documentation, accident prevention, nutritional status, drug regimen reviews, food sanitation, and infection control. The Plan of Correction outlines corrective actions including staff education, care plan revisions, audits, and monitoring for substantial compliance.

The inspection was triggered by a complaint investigation #74814.

The facility failed to review and revise care plans for residents at risk of falls, failed to develop initial care plans timely, failed to prevent falls resulting in injuries, failed to provide adequate nutritional monitoring, failed to monitor side effects of antipsychotic medications through required assessments, failed to maintain sanitary food service conditions, and failed to properly track and trend infections.

The facility failed to maintain sanitary conditions in the dietary areas, including dust and discoloration on kitchen equipment and food particles on floors and tables, risking food borne illnesses to residents.

The survey found the most serious deficiencies to be level 'F', 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, resulting in a finding of substantial compliance.

The plan outlines corrective actions for deficiencies related to individualized care plans for fall risk, bladder incontinence care, accident hazard prevention, food sanitation, and medication management including expired medications.

The revisit confirmed that all previously identified deficiencies related to regulations 483.20(d)(3), 483.10(k)(2), 483.25(d), 483.25(h), 483.35(i), and 483.60(b), (d), (e) were corrected as of the revisit date.

The complaint investigation #63975 identified failures in care plan revisions, supervision to prevent elopement, infection prevention, sanitation, and medication management.

The facility failed to review and revise care plans to prevent repeated falls for residents, failed to provide appropriate treatments to prevent urinary tract infections, failed to ensure adequate supervision to prevent elopement and accidents, failed to maintain sanitary conditions in kitchenettes, and failed to monitor and dispose of expired medications.

The facility had deficiencies related to food items not being labeled with expiration dates, improper positioning of the ice machine drain tube, buildup of dirt on kitchenette floors, and inadequate cleaning of trash cans. The plan outlines corrective actions including staff education, cleaning schedules, and monitoring procedures.