Kansas Soldiers Home

In the surveyor’s words

From the most serious findings on record at Kansas Soldiers Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 22, 2021

  The facility census totaled 25 residents, with four residents included in the sample for abuse, neglect, and exploitation. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 was free from resident-to-resident abuse by R3 when the residents had three altercations, which led to R1 receiving a bloody nose and cut lip during one incident and a [CONDITION(S)] (requiring surgical repair) during another altercation. On 04/15/21, R3 shoved R1 and grabbed R1's wrist. On 05/17/21, R1 wandered into another resident's room, who started yelling at R1. R3 then entered the room and pushed R1, causing a bloody nose and a cut to the lip. Then on 06/10/21, R1 walked by R3's room and R3 pushed him down. R1 received a hip fracture, which required surgery. […]

• Actual harm, isolatedF686Aug 7, 2025

  The facility identified a census of 51 residents. The sample included 12 residents, including one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to address and implement measures consistent with professional standards of practice to prevent the development of and promote the healing of pressure ulcers for Resident (R) 32 when staff failed to ensure R32 received pressure reducing interventions, repositioning, and physician involvement at the time the initial changes were identified. […]

• No harm, potential for more than minimal, widespreadF730Aug 7, 2025

  The facility reported a census of 51 residents. The facility identified five Certified Nurse Aides (CNA) employed for over 12 months during the review period. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for the five CNAs reviewed, to ensure adequate and appropriate care and services were provided to the residents of the facility. This placed the residents at risk for decreased quality of care. […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2025

  The facility reported a census of 51 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.Findings included: - During a second tour of the kitchen on 08/5/25 at 10:30 AM, observation revealed three-barrel type trash cans that did not have a lid covering the trash cans. Dietary Staff DD did ask the staff to locate the lids to the trash cans, and all but one was found. On 08/0525 at 10:35 AM, observation revealed Dietary Staff DD washed her hands, then put on gloves, and pureed the food for five residents, which included country fried steak and asparagus. […]

• No harm, potential for more than minimal, widespreadF814Aug 7, 2025

  The facility reported a census of 51 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. This placed facility residents at risk for insect or rodent infestation.Findings included: - During a second tour of the kitchen on 08/5/25 at 10:30 AM observation revealed three-barrel type trash cans which did not have a lid. Dietary Staff DD did ask the staff to locate the lids to the trash cans and all but one was found.On 08/06/25 at 03:15 PM observation of the outside garbage bins with Certified Dietary Manager (CDM) BB revealed eight trash bins against the fence and two of the bins had lids up. […]