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Good Samaritan - Atwood

650 Lake Road #216, Atwood, KS 67730 · Non profit - Corporation · 35 certified beds · (785) 626-9015 Medicare & Medicaid certified

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Abuse/neglect citations on record (F0609, F0610) — most recent Jul 20243 immediate-jeopardy citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$68,956 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0609, F0610) — most recent Jul 2024
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $68,956 in federal fines (most recent 2024-07-31)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
71434 Highway 25 · (308) 334-5241 · Call to confirm hours
Pharmacy
416 State St · (785) 626-3214 · Call to confirm hours
Grocery
701 N 4th St
Park
Columbia Park · Typically dawn to dusk
Place of worship
200 N 4th St · (785) 626-3855

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.6%17.9%15.4%worse
Long-stay residents who lose too much weight1.1%4.9%5.4%better
Long-stay residents with a catheter left in their bladder1.6%1.6%0.9%worse
Long-stay residents with a urinary tract infection1.1%2.9%2.0%better
Long-stay residents with depressive symptoms1.1%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.3%4.3%3.3%worse
Long-stay residents whose ability to walk worsened20.2%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication31.9%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers7.5%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control19.4%22.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table4.9%18.1%17.1%better
Long-stay hospitalizations per 1,000 resident days1.731.801.67typical
Long-stay outpatient ER visits per 1,000 resident days3.082.131.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.02U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
<0.01hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.02 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.06
RN hours/ resident / day
0.66
LPN hours/ resident / day
1.86
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.76
RN hoursweekends
22.2%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 35 beds and averages 25.8 residents a day — about 74% occupied, or roughly 9 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.17 hrs/resident/day on weekends vs 3.74 on weekdays — 15% thinner on weekends. RN hours go from 1.18 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 22% is below the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2025-06-18)
8
at the previous standard inspection (2023-09-28)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 14 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · K2024-07-31 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to investigate an allegation of sexual abuse and initiate protective measures until an investigation was completed. On 07/24/24 at 09:37 PM Resident (R)1 told her daughter that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. LN G told R1's representative she would go down and talk to R1 and report the incident to Administrative Nurse D. At 11:00 PM, R1 asked LN G if she had told the nurse that she was molested. On 07/25/24 R1's representative arrived at the facility and spoke with LN G. LN G told R1's representative she felt R1 may have been…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-07-31 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported Resident (R)1's allegation of sexual abuse to the Licensed Nursing Home Administrator (LNHA) and further failed to report the sexual abuse allegation to the required state agencies including law enforcement. On 07/24/24 at 09:37 PM, R1 told her representative that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. LN G told R1's representative she would go down and talk to R1 and report the incident to Administrative Nurse D. At 11:00 PM, R1 asked LN G if she had told the nurse that she was molested. LN G did…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 27. The sample included three residents reviewed for pressure injuries/ulcers. Based on record review and interview, the facility failed to ensure adequate treatment to prevent the worsening of a facility acquired pressure ulcer and failed to promote healing. On 12/15/23, Resident (R) 1, who required assistance from two staff for bed mobility, developed a facility acquired unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer to her left heel. The facility applied heel protectors but did not involve the provider until seven days later. The provider ordered a dressing to the wound, changed every seven days. The wound became stagnant and lacked any signs of healing from 12/22/23 through 03/23/24 when a new treatment was started. The facility also did not measure the wound for two weeks from 03/09/24 through 03/22/24. On 03/29/24, the facility spoke with the dietician and the telehealth wound nurse and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-01-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 34 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to prevent a fall with major injury to Resident (R) 1. On 12/11/23 at approximately 07:45 AM, Certified Nurse's Aide (CNA) M failed to apply the safety belt in the bath chair. As a result of this failure, R1 sustained a displaced intertrochanteric (area between the greater and lesser hip bone) fracture (broken bone) of the right femur (the bone of the thigh). This deficient practice also placed R1 at risk for pain, decreased mobility, and impaired quality of life. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated 11/21/23, documented R1 had a Brief Interview for Mental Status score of three, which…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · F2025-06-18 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 26 residents. The sample included 12 residents. Based on record review and interview, the facility failed to deliver mail to the facility residents on Saturdays. This deficient practice placed the residents at risk for not having reasonable access to send or receive written communications. Findings included: - On 06/16/25 at 08:00 AM, on entrance to the facility, observation revealed a white basket sitting on a desk inside the front entry door, labeled United States Postal Service (USPS), and it contained numerous envelopes. On 06/17/25 at 09:00 AM, during the resident council meeting, a resident verbalized that there was no mail delivery on Saturdays. The resident stated the activity director would deliver the mail Monday through Friday, but there was not a designated person to deliver on the weekends. On 06/18/25 at 10:00 AM, Administrative Nurse D verified the facility does not always deliver the residents' mail on Saturdays, and there was not a designated person assigned to deliver the mail to the residents. The facility's Resident Mail policy, dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-06-18 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 26 residents and one kitchen. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 25 residents who reside in the facility and receive their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition. Findings included: - On 06/16/25 at 08:40 AM, observation revealed the kitchen staff finishing the morning meal and preparing the midday meal. Dietary Staff (DS) stated he was the Dietary Manager. DS reported he had enrolled in a Certified course and had just begun the process of becoming a Certified Dietary Manager. The facility's Director of Food and Nutrition Services Job Orientation and Training policy, dated 12/16/24, documented to ensure consistent and proper training is provided to new directors of food and nutrition (DFN) services. All new DFNs would complete the DFN job orientation and training (JOT) program within three months of their hiring date. All learners completing the DNF JOT program are given adequate…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-18 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 26 residents. The sample included 12 residents. Based on observation and interview, the facility failed to serve the midday meal within 45 minutes of the designated time of 11:30 AM. This deficiency placed the residents at risk of an impaired dining experience. Findings included: - On 06/16/25 at 11:18 AM, Dietary Staff (DS) CC placed water, a variety of beverages, and silverware on the dining room tables. Residents entered the dining room independently or with staff assistance. Facility staff assisted the residents with shirt protectors as needed and requested. The staff shared the daily devotional reading and announced the meal was to be roast beef, fried potatoes, and cooked cabbage. On 06/16/25 at 12:16 PM, the first meal from the kitchen was served. On 06/16/25 at 12:35 PM, Resident (R) 7 and R17 had been present in the dining room since 11:30 AM, when DS CC reported the kitchen ran out of roast beef and inquired what the residents would like from the alternative menu. On 06/16/25 at 12:50 PM, R7 and R17 reported they were always served last, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store and prepare food in a sanitary manner for the residents who resided in the facility and received meals from the facility's kitchen. This placed the residents at risk for foodborne illness. Findings included: - On 06/16/25 at 08:40 AM, during initial tour of the facility's kitchen, observation revealed in the dry storage room, a case of [NAME] Pears (six #10 size cans) sitting directly on the floor, and a box of oatmeal cream pies also sat directly on the floor. Further observation revealed in the walk-in freezer a bag of sliced zucchini sitting directly on the floor of the freezer, along with a box of frozen buns. Dietary Staff (DS) BB reported that the delivery truck had come during the past week, and the supplies on the stock room floor should have been put on the shelves. DS BB reported that the zucchini and box of buns had fallen from the shelf and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-18 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    he facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 23 gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This placed the resident at risk for possible exposure to infection. Findings included: - On 6/17/25 at 9:20 AM, observation revealed License Nurse (LN) G had finished R23's nebulizer breathing treatment and was observed washing the resident's nebulizer and did not wear a gown while cleaning the nebulizer mouthpiece. On 06/18/25 at 08:00 AM, observation revealed Certified Nurse Aide (CNA) M assisted the resident to change his shirt while seated in his wheelchair. Continued observation revealed CNA M lacked gloves or a gown. Observation revealed PPE was available across the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-18 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 26 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide Resident (R) 18 or their representative the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, and failed to provide R27 or their representative the completed CMS Notice of Medicare Non-Coverage (NOMOC) form 10123. This placed the resident at risk of uninformed decisions about their skilled services. Findings included: - Review of the CMS form provided to R18 revealed the resident received the wrong form. R18 received the CMS-R-131 and the CMS 10055 form, but had not received the CMS Form 10123. The resident's skilled services ended on 06/04/25. Review of the CMS form provided to R27 revealed the resident received the wrong form. R27 received the CMS -R-131 instead of the CMS form 10055 and failed to receive the CMS 10123 form. The resident's skilled services ended on 06/08/25. The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-09-28 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk for impaired quality of care. Findings included: - The facility's employment records documented six nurse aides were employed at the facility for at least one year. The facility's in-service records documented five of the six nurse aides had not completed the required 12 hours of in-service training annually. The Facility Assessment, dated 03/30/23, stated the facility would provide ongoing education and training for the staff throughout the year on the state required topics and other topics identified by Quality Assurance and Performance Improvement (QAPI). The assessment stated competency verification checklists were created for all staff and training on dealing with behaviors would be provided routinely. On 09/27/23 at 226 PM, Administrative Nurse D verified staff did not have the required amount of in-service education.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-28 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility had a census of 33 residents. Based on observation, interview, and record review the facility failed to employ a full time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 33 residents of the facility at risk for inadequate nutrition or food borne illness. Findings included: - On 09/27/23 at 11:00 AM, observation revealed Dietary Staff (DS) CC prepared the pureed vegetables. On 09/27/23 at 11:15 AM, DS CC verified she was the facility's dietary manager, but was not certified. She stated she was enrolled and taking classes since January 2023. Upon request the facility did not provide a policy for certified dietary manager. The facility failed to employ a full time certified dietary manager to supervise the preparation of meals and sanitation in the facility's kitchen, placing the 33 residents of the facility at risk for inadequate nutrition or food borne illness.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 33 residents. Based on observation, interview, and record review, the facility failed to ensure appropriate sanitation of dishware used for preparing and serving residents' meals, and failed to monitor cold temperature storage of resident foods. This deficient practice placed the 33 residents of the facility at risk for food borne illness. Findings included: - On 09/27/23 at 11:25 PM, observation revealed Dietary Staff (DS) CC operated the dishwasher and attempted to test the dishwasher rinse for chemical sanitation. The wash and rinse temperatures were less than 135 degrees Fahrenheit (F). She used Quat sanitizer testing strips which indicated no chemicals. The dishwasher was connected to Ecolab Ultra San (bleach). The Dishwasher Temperature Logs, dated July 2023, documented morning and noon only, lacked evidence staff assessed and monitored temperatures for 21 days. The documentation lacked evidence of chemical sanitation checks. The Dishwasher Temperature Logs, dated August 2023, documented morning and noon only, from 08/11/23 to 08/31/23 lacked…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the environment remained free of accident hazards related to unlocked chemicals and unsecured hydocollator for five cognitively impaired, independently mobile residents. This placed the residents at risk for preventable accidents and injuries. Findings included: - On 09/28/23 at 07:30 AM, observation revealed an unlocked physical therapy room on the 300 Hall including one unattended hydrocollator (liquid heating device used in physical therapy to heat and store hot packs). On 09/28/23 at 7:35 AM, observation revealed an unlocked chapel room on the 300 Hall included the following items: One gallon-size jug of Superior Loot Formica Contact Adhesive, with the warning label may cause skin and eye irritation, and keep out of reach of children. Three four-gallon buckets of LokWork Resilient Adhesive, with the warning label may cause skin and eye irritation and use with local exhaust ventilation. One 32 ounce plastic bottle of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2023-09-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 12 residents with two reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide personal grooming assistance and cares for Resident (R) 28. This placed the resident at risk for poor hygiene and impaired dignity Findings included: - R28's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental dosirder characterized by failing memory and confusion,) psychosis (any major mental disorder characterized by a gross impairment in reality perception,) major depressive disorder (disorder which causes persistent feeling of sadness,) and anxiety (mental or emotional reaction characterized by apprehensio, uncertanity and irrational fear.) R28's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status score of two indicating severe cognitive impairment. The MDS recorded R28 required extensive assistance of one…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, interview, and record review the facility failed to involve the physician and Registered Dietician (RD) in an adequate timeframe after Resident (R) 26 experienced a large weight loss in 11 days in April 2023. This deficient practice placed R26 at risk for further weight loss or health issues. Findings included: - R26's Electronic Medical Record documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), pain, anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), and adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident(R)1's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen, stored in the medication room, with the date openedand discard date. This deficient practice placed the affected resident at risk for ineffective medications. Findings included: - On [DATE] at 10:30 AM, observation of the facility's medication room revealed the following: R1's basaglar (long-acting insulin) flex pen lacked an open date and discard date. On [DATE] at 10:35 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the expired insulin. On [DATE] at 10:45 AM, Administrative Nurse D verified the nurses should label and date the flex pens with the resident's name and discard expired pens. The facility's Storage of Medication policy dated [DATE] documented insulin pens would be clearly labeled with the name of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-16 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 34 residents. Based on observation, record review and interview, the facility failed to treat the resident's with dignity promoting quality of life when the facility failed to serve meals at the same time to all residents seated at the same table. This placed the residents at risk for impaired dignity and decreased psychosocial wellbeing. Findings included: - On 06/13/22 at 12:20PM, dining observation revealed two different tables with four residents seated at each table. Further observation revealed two residents were served the lunch meal while the other two residents at the table were not served until the first two residents were done eating. On 06/14/22 at 8:10AM, dining observation revealed four residents seated at the dining table. One of the residents was served breakfast but the other three residents were not served breakfast until the first one finished. On 06/15/22 at 12:45PM, dining observation revealed three residents seated at a dining table. Two of the residents were served the lunch meal and completed the meal before the third resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-16 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide activities of daily living (ADL) assistance at mealtime for seven residents who required staff assistance with eating. This placed the residents at risk for poor nutrition and weight loss. Findings included: - On 06/13/22 at 11:30 AM, dining observation revealed two tables reserved for residents who required moderate to total assist with meals. Three residents (Resident (R)16, R18, R19, R29, R34, and R136) were at each table, seated in wheelchairs or Broda chairs. Further observation revealed the dietary staff passed out drinks and placed drinks in front of the moderate to total assist residents at the two tables though no staff were present to assist. On 06/13/22 at 12:10 PM, continued dining observation revealed no direct care staff had yet assisted the moderate to total assist residents with their drinks. Resident (R)34 attempted to get a drink by herself and tipped over her cup in the effort. The drink was all over the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-16 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to provide weekend activities. This deficient practice placed the residents in the facility at risk for boredom and decreased socialization. Findings included: - On 06/14/22 at 03:15 PM during discussion with the residents of the resident council, all five residents verbalized no activities were available on Saturday and Sundays. Review of the March, April, May, and June 1st-June 11,2022 activity calendars revealed no activities listed on Saturday or Sundays. On 06/15/22 at 1:40 PM, Activity Staff Z verified there were no weekend activities offered. Activity Staff Z stated the facility should plan and schedule some weekend activities. The facility's Activity Program policy, dated 08/25/21, informed staff that leisure and recreation are important components of daily life and an integral part of holistic care. The facility should develop, large, small group and one to one activities. The facility failed to provide an activity program for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-16 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review and interview dietary staff failed to effectively carry out the meal preparation and food service in a manner which allowed for prompt meal delivery and facilitated social dining for the 34 residents residing in the facility, placing them at risk for impaired nutrition and decreased quality of life. Findings included: - On 06/13/22 the posted facility mealtimes were: Breakfast 8:00 AM, Lunch 11:30 AM, Supper 5:00 PM. On 06/13/22 at 11:30 AM, observation revealed 32 of the 34 residents in the facility were seated in the dining room. On 06/13/22 at 11:50 AM, observation revealed dietary staff passed drinks to the residents and took residents' lunch orders. Further observation revealed the first plate served from the kitchen was at 12:10 PM , approximately 40 minutes after the scheduled mealtime. On 06/13/22 at 12:30 PM, observation revealed a resident propelled her wheelchair out of the dining room and stated, I will skip the dessert, I am tired of waiting. On 06/13/22 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-16 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserve nutritive value, flavor, and appearance for four residents who received pureed diets placing the residents at risk for inadequate nutrition. The facility further failed to ensure appropriate temperatures for food items served in the dining room. This placed the residents at risk for food borne illness. Findings included: - On 06/13/22 at 11:20 AM, observation revealed Dietary Staff (DS) BB prepared pureed meals for four residents. DS BB placed four polish kielbasa (type of meat sausage) into a robo coupe (a blender), then added beef broth with a spoon without measuring. DS BB placed oven roasted vegetables (broccoli, carrots and squash) in the robo coupe and blended without measuring. On 06/13/22 at 11:30 AM, observation revealed Dietary Staff BB served the noon meal to Resident (R)16 and R48 at the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-16 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 14 residents with one reviewed for discharge. Based on record review and interview, the facility failed to notify the State office of Long-Term Care Ombudsman (LTCO) of a facility-initiated transfer for Resident (R) 8. This placed the resident at risk for impaired coordination of care, and loss of rights related to facility-initiated discharge and/or transfer. Findings Included: - R8's Electronic Medical Record included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behaviors, insomnia (inability to sleep) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R8's Annual Minimum Data Set dated 03/09/22 recorded R8 had a brief interview for mental Status score of three which indicated severe cognitive impairment. R8 had behaviors directed towards other one to three days of the look back period. He requires supervision with most activities of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 37 residents. The sample included 14 residents with six reviewed for accidents. Based on observation, record review and interview, the facility failed to provide a safe environment and adequate supervision for one of the six sampled residents, Resident (R) 6, who had an unsupervised fall and sustained a minor injury. This placed the resident at risk for further accidents and injuries. Findings included: - R6's Electronic Medical Record (EMR) recorded diagnosis of congestive heart failure (the heart can not pump enough blood to meet the body's needs), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). The Annual Minimum Data Set (MDS), dated [DATE], recorded the resident had moderately impaired cognition, and required minimal assistance with locomotion The MDs recorded R6 had one non injury fall. The Cognitive Loss Care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-16 · tag F0849 — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 14 residents with one reviewed for hospice services. Based on observation, record review, and interview the facility failed to ensure coordination between the hospice provider and the facility for Resident (R) 34, who was admitted to hospice on 02/12/22, which included a plan of care from the hospice and a description of the services provided including visit frequency, medications and medical equipment. This placed the resident at risk of delayed or inadequate care. Findings included: - R34's Electronic Medical Record (EMR) documented the resident had diagnoses chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure, dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, unstable angina (chest discomfort or shortness of breath caused when heart muscles receive…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-09-28 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure the results of the most recent survey (the last standard survey, extended surveys, or subsequent complaint suveys with citations) results were available for public review. - On 09/26/23 at 08:30 AM, surveyors reviewed the Survey Result Binder in the plastic storage container on the East wall close to the Administrator's office. The facility failed to ensure the Statement of Deficiencies (SOD) from the 10/12/23 complaint survey which resulted in a citation was available for review. On 09/26/23 at 08:32 AM, Administrative Staff A verified the 10/12/22 complaint survey SOD was not in the survey binder. Administrative Staff A then retrieved the results and added them to the binder. Upon request, the facility did not provide a policy for posting of the survey investigation results. The facility failed to make available in a readily accessible area the last complaint survey SOD available for public review, placing, the residents, staff and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$68,956 in federal fines across 3 penalties.

  • $51,146 — penalty dated 2024-07-31
  • $8,499 — penalty dated 2024-05-09
  • $9,311 — penalty dated 2024-01-03

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.0-1.0 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 5 of 54.0+1.0 vs chain
Quality measures 2 of 52.8-0.8 vs chain
The other 91 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Edgebrook Care CenterEdgerton, MN 1 of 5Good Samaritan - IndianolaIndianola, IA 1 of 5Good Samaritan - Red OakRed Oak, IA 1 of 5Good Samaritan Society - AtkinsonAtkinson, NE 1 of 5Good Samaritan Society - BlackduckBlackduck, MN 1 of 5Good Samaritan Society - Grand Island VillageGrand Island, NE 1 of 5Good Samaritan Society - LakotaLakota, ND 1 of 5Good Samaritan Society - Mary Jane BrownLuverne, MN 1 of 5Good Samaritan Society - St Luke's VillageKearney, NE 1 of 5Good Samaritan Society - WindomWindom, MN 1 of 5Good Samaritan Society De SmetDe Smet, SD 1 of 5Good Samaritan Society MillerMiller, SD 1 of 5Salem Lutheran HomeElk Horn, IA 1 of 5Souris Valley Care CenterVelva, ND 1 of 5St Vincent's - A Prospera CommunityBismarck, ND 1 of 5Sunset Drive - a Prospera CommunityMandan, ND 2 of 5Good Samaritan - Decatur CountyOberlin, KS 2 of 5Good Samaritan - EsthervilleEstherville, IA 2 of 5Good Samaritan - MansonManson, IA 2 of 5Good Samaritan - OttumwaOttumwa, IA 2 of 5Good Samaritan - WaukonWaukon, IA 2 of 5Good Samaritan Society - BottineauBottineau, ND 2 of 5Good Samaritan Society - Hastings VillageHastings, NE 2 of 5Good Samaritan Society - OakesOakes, ND 2 of 5Good Samaritan Society - Park RiverPark River, ND 2 of 5Good Samaritan Society - Specialty Care CommunityRobbinsdale, MN 2 of 5Good Samaritan Society - St John'sKearney, NE 2 of 5Good Samaritan Society - St Martin VillageRapid City, SD 2 of 5Good Samaritan Society - SuperiorSuperior, NE 2 of 5Good Samaritan Society - Waconia And Westview AcreWaconia, MN 2 of 5Good Samaritan Society CantonCanton, SD 2 of 5Good Samaritan Society Luther ManorSioux Falls, SD 2 of 5Good Samaritan Society New UnderwoodNew Underwood, SD 2 of 5Good Samaritan Society Sioux Falls CenterSioux Falls, SD 2 of 5Good Samaritan Society Sioux Falls VillageSioux Falls, SD 2 of 5Good Samaritan-LiberalLiberal, KS 2 of 5The Good Samaritan Society-Kissimmee VillageKissimmee, FL 3 of 5Good Samaritan - AlgonaAlgona, IA 3 of 5Good Samaritan - DavenportDavenport, IA 3 of 5Good Samaritan - HolsteinHolstein, IA

Showing 40 of 91; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
SANFORDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2019
THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETYOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 01/01/2019
BROWN, GEORGEIndividualCORPORATE DIRECTORsince 01/01/2025
DYKHOUSE, DANAIndividualCORPORATE DIRECTORsince 05/30/2024
ENGBRECHT, WESLEYIndividualCORPORATE DIRECTORsince 05/30/2024
GASSEN, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/30/2024
GULSVIG, NEILIndividualCORPORATE DIRECTORsince 05/30/2024
HERSETH SANDLIN, STEPHANIEIndividualCORPORATE DIRECTORsince 05/30/2024
LUNDEEN, MARKIndividualCORPORATE DIRECTORsince 05/30/2024
MCCAUSLAND, MAUREENIndividualCORPORATE DIRECTORsince 01/01/2025
MOLBERT, LAURISIndividualCORPORATE DIRECTORsince 05/30/2024
NORTH, ANDREWIndividualCORPORATE DIRECTORsince 05/30/2024
SCHIEFFER, KEVINIndividualCORPORATE DIRECTORsince 01/01/2025
SHULKIN, DAVIDIndividualCORPORATE DIRECTORsince 05/30/2024
TEIKEN, BRENTIndividualCORPORATE DIRECTORsince 05/30/2024
VENTLING-HERRMANN, MARNIEIndividualCORPORATE DIRECTORsince 05/30/2024
WENZEL, THOMASIndividualCORPORATE DIRECTORsince 01/01/2025
FLUIT, JOELIndividualCORPORATE OFFICERsince 10/01/2022
MIDDLETON, AIMEEIndividualCORPORATE OFFICERsince 01/27/2022
OLSON, NICHOLASIndividualCORPORATE OFFICERsince 04/08/2024
SCHEMA, NATHANIndividualCORPORATE OFFICERsince 01/01/2022
KUHLMAN, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/25/2018
MORRISON, TONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
PORTSCHY, JACQUELINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/22/2022

CMS files one row per role, so the 28 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.6M
Net patient revenuemost recent cost report
+7.8%
Operating marginrevenue minus expenses
$471K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 61%Medicare 2%Other / private 37%

This home reported $471K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$261per resident / day
operating cost
$7,943per month
≈ monthly operating cost
$283per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.

Typical monthly cost in Kansas
$8,669/mo
Nursing home (semi-private)
$9,064/mo
Nursing home (private)
$5,975/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175366. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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