Heritage Health Care Center
1630 W 2nd Street, Chanute, KS 66720 · For profit - Limited Liability company · 60 certified beds · (620) 431-4151 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has 1 actual-harm citation
- 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $27,860 in federal fines (most recent 2026-03-04)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 fell from 3 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 26.6% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.6% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.9% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 4.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 24.5% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 34.7% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.9% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 35.4% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.4% | 18.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 75.0% | 73.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.0% | 22.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.7% | 11.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.50 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 6.02 | 2.13 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
59.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 169 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 90 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.8%CMS range 52.1–66.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.0%CMS range 10.3–18.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 58.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 4.2–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.42 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this 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
How full it usually is: this home is certified for 60 beds and averages 53.9 residents a day — about 90% occupied, or roughly 6 beds typically open. It runs fairly full. 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 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.91 is at or above 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 3.62 hrs/resident/day on weekends vs 4.36 on weekdays — 17% thinner on weekends. RN hours go from 0.43 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
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
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.
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.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2026-03-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 reported a census of 53 residents. Based on observation, interview and record review, the facility failed to ensure Resident (R) 3 remained free from abuse when he had an unwitnessed fall in his room and Licensed Nurse (LN) G instructed R3 to get onto his hands and knees and lift himself off the floor resulting in feelings of anger and embarrassment for R3.Findings included:- R3's Electronic Health Record (EHR) revealed diagnoses of unspecified sequelae of cerebral infarction (lingering, long-term effects or complications following a stroke [ischemic brain damage] when the specific nature of the aftereffects is not detailed), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R3's Admit Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment documented R3 utilized a wheelchair and walker for mobility. He was dependent on staff for toileting, lower body…
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.
- Actual harm · Gcited before2023-12-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 reported a census of 52 residents, with 17 sampled, including three residents reviewed for pressure ulcers/injuries. Based on observation, interview and record review, the facility failed to assess and provide preventive pressure ulcer treatment for two of the three residents reviewed. Resident (R) 109 developed unstageable pressure injuries on her bilateral heels, left lateral foot, and left anterior foot. The deficient practice placed R109 and any other resident with potential skin issues, at risk of further pressure injury development. Findings included: - Review of Resident (R)109's Physician Order Sheet, dated 12/06/23, included diagnoses of: fractured (broken bone) left femur (bone in thigh), cervical vertebrae (spinal bones in the neck) fracture, left foot drop (inability or difficulty in moving the ankle and toes upward), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and acute kidney failure (inability of the kidneys to…
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.
- Potential for harm · Dcited before2026-03-04 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 53 residents. Based on record review, observation, and interview, the facility failed to ensure narcotic reconciliation which included regular narcotic counts of all narcotics, including the narcotics stored as overflow. Findings included:-In a facility reported incident, the facility reported that on 02/13/26 at approximately 02:00 PM, staff reported 12 hydrocodone (a potent semi-synthetic opioid analgesic and antitussive used to treat severe pain) were missing.The facility Facility Narcotic Dispensing Record for R1's hydrocodone medication documented that a count of 30 had been crossed out with a line and a count of 18 had been written in and initialed by two individuals and dated and times 02/12/26 at 11:00 PM. It was documented and initialed an amount given of one with the remaining amount of 17.Licensed Nurse (LN) H's Witness Statement, dated 02/16/26, documented that on 02/12/26 she was asked to pull a hydrocodone from the overflow medication, and she and Certified Medication Aide (CMA) R performed a count of the medication in the bottle…
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.
- Potential for harm · Fcited before2025-08-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 reported a census of 59 residents, one main kitchen, and two kitchenettes. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for foodborne bacteria. This placed the residents at risk of foodborne illnesses.Findings included:- During an initial tour of the kitchen on 08/04/25 at 11:04 AM, the following areas of concern were noted:The microwave in the dining room was heavily soiled with dried-on food debris on the inside and outside of the microwave oven.The window area used to pass dirty dishes from the dining room to the kitchen had a heavy build-up of dried-on food and liquid on the frame of the window, the cove base underneath the window, and the trash can next to the window had dried-on food substance. The window area used to pass resident plates from the kitchen into the dining room had a heavy build-up of dried-on food and liquid. The stationary can opener had a build-up of a moist food substance on the base of the opener. The preparation table next to the stove, used…
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.
- Potential for harm · F2025-08-06 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 59 residents. Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the covers on three of the three dumpsters were kept closed. This deficient practice created a risk of attracting insects and/or rodents.Findings included:- During an initial environmental tour of the kitchen on 08/04/25 at 08:19 AM, observation revealed the lids to three of the three dumpsters outside of the kitchen were left open, with trash on the ground surrounding the dumpsters.On 08/04/25 at 09:15 AM, the lids of the dumpsters remained open.On 08/06/25 at 10:35 AM, Dietary Staff BB stated that staff were to keep the lids of the dumpsters closed at all times.The facility policy for Disposal of Garbage and Refuge undated, included: Dumpsters shall be kept covered when not being loaded. The surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attraction is minimal.
- Potential for harm · Ecited before2025-08-06 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 59 residents with two medication rooms, three medication carts, and two treatment carts. All five carts have a narcotic box. Based on observation, interview, and record review, the facility failed to adequately reconcile the medication cart for controlled substances. This placed the residents at risk for misappropriation. Findings include:- On 08/04/25 at 12:30 PM, the cart in the east hallway contained a lock box that contained controlled substances. Review of the controlled substance reconciliation log lacked evidence of a controlled substance reconciliation between two staff on 07/03/25 at 08:00 PM; only the day shift nurse signed off. The log lacked evidence that a reconciliation was completed on 08/04/25 at 06:00 AM shift. There were no signatures present. On 08/04/25 at 12:30 PM, Certified Medication Aide (CMA) S stated the narcotics should be counted and verified every time the cart changes hands. CMA S said the outgoing nurse, the on-coming nurse, and the CMA all sign for the accuracy of the controlled substances on the cart.On 08/06/25 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.
- Potential for harm · E2025-08-06 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 reported a census of 59 residents, three medication carts, two treatment carts, and two medication rooms. Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled, stored, and secured adequately. This placed the affected residents at risk for ineffective medication regimens or diversion.Findings included:- During an observation on [DATE] at 12:30 PM in the east hall, a medication cart was unlocked and unattended. The cart contained various medications, including Talzenna (a cancer medication), Gabapentin (a medication to relieve nerve pain), and narcotics in a lock box. On [DATE] at 01:03 PM, the east treatment cart was observed. The top drawer contained Novolog (a short-acting insulin that lowers the level of glucose in the blood) that was opened on [DATE]. This would have expired on [DATE]. It also contained Tresiba (long-acting insulin) and Lantus (long-acting insulin) that were not dated when they were opened,…
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.
- Potential for harm · D2025-08-06 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 59 residents. The sample included 17 residents, including six residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure informed consent including purpose, risks versus benefits, and expected therapeutic benefits for the use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), anxiolytic (medication used to treat symptoms of anxiety) and other psychotropic medications (drugs that affect the brain and nervous system to treat mental illnesses) for Resident (R) 6. This placed the resident at risk for uninformed treatment decisions.Findings included:- R6's Electronic Medical Record (EMR) documented the following diagnoses: panic disorder (an anxiety disorder) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R6's EMR documented the following physician's orders:Duloxetine (an antidepressant medication), 120 milligrams (mg), by mouth, every morning, for a diagnosis of depression, ordered…
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.
- Potential for harm · D2025-08-06 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 reported a census of 59 residents. The sample included 17 residents, including one resident reviewed for discharge. Based on interview and record review, the facility failed to provide the Ombudsman (a resident advocate) with a notice of transfer for Resident (R)67 and R69. This placed the residents at risk of impaired residents rights related to discharge. Findings included: -R69's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She was admitted to the facility on [DATE] with a goal to discharge to the community.The Return to Community Referral Care Area Assessment (CAA), dated 04/22/25, did not trigger.R69's Discharge MDS, dated 06/03/25, documented the resident had a planned discharge to the community.R69's Care Plan for discharge planning instructed staff to identify any resources the resident may need upon dismissal to home.R69's EMR revealed a Progress Note 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.
- Potential for harm · Dcited before2025-08-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 reported a census of 59 residents. The sample included 17 residents, including four residents who were reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide the necessary ADL care for one sampled resident, Resident (R)8, who did not get showered. This deficient practice placed the affected resident at risk for impaired quality of life and poor hygiene.Findings included:- Review of the Electronic Health Record (EHR) revealed that R8's diagnoses included cutaneous abscess of right axilla (cavity containing pus and surrounded by inflamed tissue), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), end stage renal disease (ESRD- the kidneys are no longer able to adequately support the body's needs), periprosthetic fracture around internal prosthetic right knee joint (a break in the bone surrounding the knee replacement implant), pressure ulcer of sacral region Stage 2…
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.
- Potential for harm · Dcited before2025-08-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 reported a census of 59 residents. The sample included 17 residents, with four residents reviewed for wounds. Based on observation, interview, and record review, the facility failed to provide the necessary wound care and services in accordance with professional standards of practice, including wound assessments at least weekly, including measurements and description, for Resident (R) 58 and R2. This placed R58 and R2 at risk for related complications and delayed healing.Findings included:-R58's Electronic Health Record (EHR) revealed a diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypothyroidism (a condition characterized by hyperactivity of the thyroid gland), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), pressure ulcer Stage 3 (full-thickness pressure injury extending through the skin into 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.
- Potential for harm · Dcited before2025-08-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 59 residents. The sample included 17 residents. Based on interviews, record reviews and observation, the facility staff failed to implement sanitary storage of breathing treatment devices for Resident (R) 1, R18, and R3, who received nebulized (a device that changes liquid medication into a mist easily inhaled into the lungs) breathing treatments. This deficient practice had the potential to spread infections to the residents in the facility.Findings included:- Observed on 08/04/25 at 01:22 PM, R18 was wearing oxygen; the tubing and humidifier bottle were not dated. Her nebulizer equipment and tubing were sitting loosely on a chair, open to the air, and not dated. R18 reported that her nebulizer is left on her chair open to air regularly.Observed on 08/05/25 at 10:33 AM, R18's nebulizer equipment was sitting on her bedside table on paper towels. R18 reported she had her breathing treatment, and the staff had cleaned and set it on the paper towel to dry. The nebulizer tubing was attached to the machine sitting on the floor and chair; none of 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.
Show the remaining 18 citations
- Potential for harm · Fcited before2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 reported a census of 52 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria and the facility failed to utilize pasteurized eggs (gently heated in their shells, just enough to kill the bacteria) for soft cooked eggs for residents. Findings included: - During an initial tour on 12/12/23 at 08:01 AM, the following areas of concern were noted: 1. The reach-in freezers had food and frozen liquid debris on the bottom. 2. The refrigerator had food debris on the bottom. 3. A white wooden box used to hold the sugar, flour and brown sugar containers had a dusty, sticky substance covering the surface. 4. Three rolling carts each with three tiers had dried-on food debris and a build-up of food debris in the grooves of the handles of the cart. 5. A shelf directly above a food preparation table had a layer of food debris and dust. 6. A shelf holding plastic containers of sugar, creamer and artificial…
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.
- Potential for harm · F2023-12-14 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 52 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS {i.e., Payroll Base Journal (PBJ)}, related to licensed nursing staff coverage 24 hours a day and excessively low weekend nursing staff. Findings included: - Review of the CASPER/PBJ Report Data revealed the following triggered areas: 1. Quarter four of 2022 (July 1 through September 30, 2022), lacked Licensed Nursing Staff on 07/02/22, 07/03/22, 07/04/22, and 07/09/22. 2. Quarter three of 2023 (April 1, 2023, through June 30, 2023) with excessively low weekend staffing. Review of the facility posting, schedule, and agency staffing invoices for Quarter four of 2022 (July 1 through September 30, 2022, revealed the facility had Licensed Nursing Staff on duty on 07/02/22,…
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.
- Potential for harm · Ecited before2023-12-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - On 12/11/23 at 03:36 PM, during a tour of the residents' beauty shop with Activity Staff Z the following concerns were identified: 1. A collection of various hair was built-up in the sink drain. 2. The countertop around the sink had various multiple hair clippings. 3. The top drawer of the sink counter held nail clippers with visible white debris, an unlabeled hair pick with hair in the teeth, and two unlabeled combs with hair in the teeth. On 12/11/23 at 03:36 PM, Activity Staff Z, verified the above findings and stated the beautician comes to the facility one time a week and should clean the beauty and the personal care items before leaving. Personal care items should be labeled and not used between residents to prevent cross contamination and prevent infections. On 12/11/23 at 03:46 PM, Administrative Staff A, verified the above findings, and stated the beauty shop was used weekly. The beautician was responsible for cleaning the beauty shop equipment and personal care items used after use. The facility…
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.
- Potential for harm · D2023-12-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 52 residents with 17 residents sampled, including two residents reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to one Resident (R)14, when staff failed to close the window blinds in the resident's room while performing catheter care. Findings included: - Review of Resident (R)14's electronic medical record (EMR) included a diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She was dependent on staff for toileting and had an indwelling urinary catheter (a closed sterile system with a catheter and retention balloon that is inserted into the bladder to drain urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/10/23, documented the resident was…
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.
- Potential for harm · D2023-12-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 reported a census of 52 residents with 17 residents sampled. Based on observation, interview and record review the facility failed to complete an individualized plan of care, regarding Activities of Daily Living (ADL) for one dependent Resident (R)46, regarding facial shaving. Findings included: - Review of Resident (R)46's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. He required setup help of staff for personal hygiene and had no rejection of cares. The Activities of Daily Living (ADL) Function/Rehabilitation Potential Care Area Assessment (CAA), dated 08/19/23, did not trigger for further review. The Quarterly MDS, dated 11/14/23, documented the resident had a BIMS score of ten, indicating moderately impaired cognition. 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.
- Potential for harm · Dcited before2023-12-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 reported a census of 52 residents with 17 selected for review. Based on observation, interview and record review, the facility failed to review and revise the care plan for two of the 17 residents. Resident (R)8 for decline in eating, and R4 for intervention for use of anipsychotic medication use. Findings included: - Review of Resident (R)8's Physician Order Sheet, dated 12/01/23, revealed diagnoses that included epilepsy (brain disorder characterized by repeated seizures), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and diabetic neuropathy ( damage of the nerves outside of the brain and spinal cord usually the hands and feet that cause weakness, numbness and pain). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated normal…
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.
- Potential for harm · Dcited before2023-12-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 reported a census of 52 residents with 17 residents sampled including four residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review the facility failed to provide appropriate assistance with personal hygiene needs for two dependent Residents (R)46 regarding facial shaving and R 21 regarding bathing. Findings included: - Review of Resident (R)46's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. He required setup help of staff for personal hygiene and had no rejection of cares. The Activities of Daily Living (ADL) Function/Rehabilitation Potential Care Area Assessment (CAA), dated 08/19/23, did not trigger for further review. The Quarterly MDS, dated 11/14/23, documented the resident had…
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.
- Potential for harm · D2023-12-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 reported a census of 52 residents with seventeen selected for review which included four residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure staff followed the care plan interventions for one Resident (R)8 of the four residents reviewed for accidents. R8 sustained two falls without the use of interventions with nonskid socks/slippers when in bed as care planned. Findings included: - Review of Resident (R)8's Physician Order Sheet, dated 12/01/23, revealed diagnoses that included epilepsy (brain disorder characterized by repeated seizures), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) congestive heart failure(a condition with low heart output and the body becomes congested with fluid) and diabetic neuropathy (damage of the nerves outside of the brain and spinal cord usually the hands and feet that cause weakness, numbness and pain). The admission Minimum Data Set (MDS),…
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.
- Potential for harm · Dcited before2023-12-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 reported a census of 52 residents with 17 residents sampled including two residents reviewed for bowel and bladder. Based on observation, interview and record review, the facility failed to use a leg anchor to prevent the tubing from being tugged on for dependent Resident (R)14's indwelling urinary catheter (a closed sterile system with a catheter and retention balloon that is inserted into the bladder to drain urine). Findings included: - Review of Resident (R)14's electronic medical record (EMR) included a diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She was dependent on staff for toileting and had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/10/23, documented the resident was dependent on staff 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.
- Potential for harm · D2023-12-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 reported a census of 52 residents with 17 selected for review which included seven residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to ensure the Registered Dietician assessed three of the seven residents reviewed for nutritional needs in a timely manner. The facility failed to evaluate and implement strategies for optimal nutritional intake for Resident(R)107 following esophagus surgery, R 109 with a post operative wound and multiple pressure ulcers and R8 to maintain weight. Findings included: - Review of Resident (R)107's Physician Order Sheet dated 11/01/23, revealed diagnoses included aftercare of paraoesophageal hernia (part of the stomach pushes the stomach into the chest through an opening in the muscle wall (diaphragm which separates the organs in the chest and abdomen also known as Hiatal hernia), dysphagia (difficulty swallowing), and post operative anemia (condition without enough healthy red blood cells to carry adequate oxygen to…
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.
- Potential for harm · Fcited before2022-03-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 reported a census of 50 residents. Based on observation, interview and record review, the facility failed to provide sanitary food preparation, storage and serving to prevent the spread of food borne illness to the residents of the facility. Findings included: - Initial environmental tour of the kitchen, on 03/21/22 at 10:02 AM, revealed the following items/areas of concern in the kitchen's refrigerator. 1. Two, opened and undated, packages of shredded cheese. 2. One gallon opened and undated container of pickle relish. 3. Two opened undated gallon containers of thousand island dressing. 4. One opened and undated, half gallon container, of enchilada sauce. 5. One opened and undated container of chocolate syrup. 6. One opened and undated 16-ounce (oz) container of cottage cheese with printed out expiration date of 03/07/22. 7. One opened and undated 32 oz container of mustard. 8. One unopened, 12 oz bottle of poppyseed dressing, with an expiration date printed of 12/06/21. 9. One opened and undated 32 oz container of lime juice. 10. Five squeeze bottles of salad dressing…
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.
- Potential for harm · D2022-03-24 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 reported a census of 50 residents with 15 selected for review which included one resident reviewed for choices. Based on observation, interview and record review, the facility failed to ensure encouragement for the one sampled resident (R)100, to voice preferences choices for beverages and food. Findings included: - Review of resident (R)100's Physician's Order Sheet, dated 03/16/22, revealed diagnoses included intraparenchymal hematoma (bleeding within the brain), arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement), cataracts (clouding of the lens of the eye), and hypertension(elevated blood pressure.) The admission Minimum Data Set (MDS), was listed as in progress. The Baseline Care Plan, dated 03/16/22, instructed staff the resident intended to return home after receiving therapy. The resident was on a regular diet and needed to be fed. The resident's height was 60 inches with a weight of 109.2 pounds. Review of the electronic medical…
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.
- Potential for harm · Dcited before2022-03-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 reported a census of 50 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to review and revise the plan of care for two of the 15 residents. Resident (R)33 to prevent further bruising following a large bruise on her hand and R15 with implementation of hospice services. Findings included: - Review of R33's Physician Order Sheet, dated 03/01/22, revealed diagnoses included dementia (progressive mental disorder characterized by failing memory, confusion) , delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident had severely impaired cognitive status, was dependent on staff for bed mobility 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.
- Potential for harm · Dcited before2022-03-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 reported a census of 50 residents with 15 residents sampled including three residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide Resident (R)147 with adequate bathing opportunities to maintain good personal hygiene. Findings included: - Review of the electronic medical record (EMR) for Resident (R)147, revealed admission to the facility on [DATE], and under the Med Diag tab, it included the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion) and legal blindness (central visual acuity of 20/200 or less in the better eye with the use of correcting lens). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required extensive assistance of two staff for transfers and extensive assistance of one staff for dressing and personal hygiene. The resident 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.
- Potential for harm · D2022-03-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 reported a census of 50 residents with 15 selected for review which included two residents reviewed for skin issues. Based on observation, interview and record review, the facility failed to develop interventions to prevent bruising for one of the two sampled residents (R)33 who had extensive bruising on the top of her right hand that extended into her fingers. Findings included: - Review of R33's Physician Order Sheet, dated 03/01/22, revealed diagnoses included dementia (progressive mental disorder characterized by failing memory, confusion) , delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident had severely impaired cognitive status, was…
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.
- Potential for harm · Dcited before2022-03-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 reported a census of 50 residents with 15 residents sampled, including one resident reviewed for pressure ulcers (PU). Based on observation, interview, and record review, the facility failed to ensure staff implemented the planned pressure reducing seat cushion to the wheelchair for the one Resident (R)147, who admitted with PUs and was at risk for further development of PUs. Findings included: - Review of Resident (R)147's electronic medical record (EMR), under the Med Diag tab, included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required extensive assistance of two staff for bed mobility and transfers and was at risk for the development of pressure ulcers. The resident admitted to the facility with two stage II (partial-thickness skin loss into but no deeper than the dermis)…
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.
- Potential for harm · Dcited before2022-03-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 reported a census of 50 residents with 15 residents sampled, including three residents reviewed for bowel and bladder. Based on observation, interview, and record review, the facility failed to properly anchor the catheter tubing and keep the catheter tubing from coming into direct contact with the floor for two of the three sampled residents, Residents (R)147 and R 19. Findings included: - Review of the electronic medical records, under the Med Diag tab for Resident (R)147, included a diagnosis of retention of urine (the inability to pass urine). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required extensive assistance of one staff for toileting and had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 03/10/22, documented the resident admitted…
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.
- Potential for harm · D2022-03-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 reported a census of 50 residents with 15 selected for review, which included six residents reviewed for unnecessary medication use. Based on interview and record review, the facility failed to obtain physician ordered lab tests to monitor PT/INR, (international normalized ratio, a blood test use to determine clotting time of the blood) to ensure two of the six sampled residents had no adverse effects of these medications. Residents (R) 36 and R102, received Coumadin (blood thinning medication). Findings included: - Review of resident (R)36's Physician Order Sheet, dated 03/01/22, revealed diagnoses included aortic valve replacement, (a heart valve between the heart and the aorta; the main artery in the heart,) heart disease and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severe cognitive impairment. The resident received one injection, seven days of antidepressant, diuretic…
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.
“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.
- 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.
Fines & penalties
$27,860 in federal fines across 2 penalties.
- $14,015 — penalty dated 2026-03-04
- $13,845 — penalty dated 2023-12-14
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 AMERICARE SENIOR LIVING — 23 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.6 | -1.6 vs chain |
| Health inspection | 2 of 5 | 3.5 | -1.5 vs chain |
| Staffing | 4 of 5 | 3.6 | +0.4 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 22 homes this chain runs (chain average 3.6★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| R H MONTGOMERY PROPERTIES, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2003 |
| MONTGOMERY, ANNA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 01/01/2013 |
| MONTGOMERY, RICHARD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 08/01/1981 |
| CROSSON, CLAY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 04/02/2002 |
| SCHADE, KYLE | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/01/2021 |
| KNAPP, MARK | Individual | W-2 MANAGING EMPLOYEE | — | since 11/14/2017 |
| AMERICARE SYSTEMS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2002 |
CMS files one row per role, so the 8 rows in the source record cover these 7 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.
This home reported $504K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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
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
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.
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 175249. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-06, 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.