Kiowa Hills Rehabilitation and Nursing, LLC

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Establish an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Services Deficiencies

Meet other general requirements that are deficient.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

A complaint survey, prompted by #CO1914646, #CO2566953, Incident #1914650 and Incident #1914652 was conducted on 8/25/25 to8/27/25. Seven deficiencies were cited. Based on observations and interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen.Specifically, the facility failed to ensure:-Hand hygiene was conducted appropriately;-Food was held at the correct temperature; and,-Room trays were covered during transportation from the kitchen to the residents’ room. Findings include:I. Failure to perform hand hygiene ap.. Based on observations, record review and interviews the facility failed to ensure recipes were followed to meet the residents’ nutritional needs.Specifically, the facility failed to follow the correct portion sizes to ensure adequate nutrition was provided to the residents. Findings include:I. Facility policy and procedureThe Food Preparation Guidelines policy and procedure, dated 4/11/25, was provided by the nursing home administrator (NHA) on 8/27/25 .. Based on observations, record review and interviews the facility failed to ensure residents consistently receive food prepared by methods that conserve nutritive value, palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents’ food was palatable in taste, texture and temperature. Findings include:I. Facility policy and procedureThe Food Preparation Guidelines, dated 4/11/25, was received by the nursing home ad.. Based on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene for one (#11) of three residents reviewed for ADLs out of 16 sample residents.Specifically, the facility failed to ensure Resident #11 was repositioned and provided with incontinence care in a timely manner.Findings include:I. Resident #11A. Resident.. Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#4) of three residents reviewed out of 16 sample residents.Specifically, the facility failed to ensure physician’s orders were followed for Resident #4’s wound care.Findings include:I. Facility policy and procedureThe Skin Care and Pressu.. Based on observations, record review and interviews, the facility failed to ensure two (#1 and #2) of four residents reviewed for abuse out of 16 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #1 and Resident #2 from physical abuse by Resident #3.III. Incident of physical abuse of Resident #2 by Resident #3 on 6/8/25A. Facility investigationThe facility’s investigation, dated 6/8/25 at 5:40 p.m., was provided b.. Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and follow up with residents who attended food committee and resident council on the outcomes and resolutions of grievances expressed regarding food. Findings include:I. Facility policy and procedureThe Resident and Family Grievances policy and proce..

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code and NFPA 72.1. Fire Alarm: No semi-annual fire alarm report availabl.. Based on a record review, it was determined that the facility failed to follow the guidance of the Life Safety Code NFPA 101. 1. Smoking policy non-compliant (no reference to smoking around oxygen in documentation presented duri.. Based on observation and document review, it was determined that the facility failed to maintain commercial kitchen equipment in accordance with NFPA 101 Life safety code. 1.Missing semi-annual hood inspection report for November.. Based on observation and document review, it was determined that the facility failed to maintain extinguisher in accordance with NFPA 101 and NFPA 10. 1.No Fire Extinguisher inspection report available for review2.Extinguisher c.. Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting records between January-August in accordance with Life Safety Code NFPA 1011.Emergency lighti.. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain electrical equipment in accordance with Life Safety Code. and NFPA 701.Extension cord in use in Kitchen2.Office 608 ha.. Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code and NFPA 1051.No four-year fire damper inspection report available for reviewNFP.. Based on observation and staff interview, it was determined that the facility failed to properly conduct a listed repair of the door to the room, secure tanks and remove all combustibles.1.Oxygen transfer room: Small Portable tanks nee.. Based on observation and staff interview, it was determined that the facility failed to properly maintain the dryer exhaust duct system and provide documentation of proper orifice replacement. 1.Dryer vent open behind unit2.Dryer.. Based on observation and staff walkthrough, it was determined that the facility failed to maintain inspection/testing records, and receptacles failed random testing of retention and ground circuit checks throughout facility in accordan.. Based on observation and staff walkthrough, it was determined that the facility failed to maintain straiwells in accordance with Life Safety Code. 1.Storage in egress stairwells under stairs (X2) NFPA 101 (12) 7.2.2.5.3* Usable Sp.. Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1. No annual fire door inspection report available for review2. Corridor door propped open 3. Storage door handle broke.. This survey was conducted in accordance with the Federal Register at Section 42 CFR Part 483.70(a).The Initial Comments (ID Prefix Tag K0000) are informational only and are a representation of the facility' s general characteristi..

A licensure survey was completed on 1/12/25 to 1/16/25. Two deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured residents received adequate supervision and assistance to prevent a fall with major injury for one (#38) of three residents reviewed for accidents/hazards out of 31 sample residents. Resident #38, who was at high risk for falls and had a history of a fall with a fracture, was admitted to the facility on 3/13/24 and readmitted on 12/25/24 after a hospital stay for repair of a right femur fracture. Per the resident' s fall care plan, staff were instructed to anticipate and meet the resident' s needs, keep the call light within reach and keep personal items within reach. Resident #38 experienced a witnessed fall on 12/20/24 while trying to walk to her sink to get a drink of water, resulting in a fracture of her right femur. The staff failed to implement new interventions after the resident' s fall with major injury.Observations of Resident #38 during the survey revealed staff were not consistently ensuring Resident #38' s call light was within reach when she was in her room. Findings include:I. Facility policy and procedureThe Safety and Supervision of Residents policy, dated 12/19/16, was provided by the nursing home administrator (NHA) on 1/15/25 at 5:07p.m. It read in pertinent part,"Our facility strives to make the environm.. Based on observations, record review and interviews, the facility failed to meet the 90 percent (%) staff vaccination rate for the influenza season. Specifically, the facility failed to:-Maintain proof of annual influenza immunizations or medical exemptions for staff; and,-Ensure staff who were not vaccinated wore masks in the facility during the influenza season.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities (9/17/24), retrieved on 1/23/25 from https://www.cdc.gov/flu/hcp/infection-control/ltc-facility-guidance.html, "CDC and the Advisory Committee on Immunization Practices (ACIP) recommend that all United States (U.S.) healthcare personnel get vaccinated annually against influenza. Healthcare personnel who get vaccinated may help to reduce transmission of influenza, staff illness and absenteeism and influenza-related illness and death, especially among people at increased risk for severe influenza complications."II. Facility policy and procedureThe Influenza Vaccine policy, revised 3/5/21, was provided by the nursing home administrator (NHA) on 1/15/25 at 12:50 p.m. It read in pertinent part,"Between October 1st and March 31st each year, the influenza vaccine shall be offered to resi..