Advena Living Of Cherryvale
1001 W Main Street, Cherryvale, KS 67335 · For profit - Limited Liability company · 45 certified beds · (620) 336-2102 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 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.
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 | 27.2% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.4% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.2% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.0% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 7.1% | 6.5% | 6.5% | typical |
| 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 | 3.0% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 44.0% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.5% | 23.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 89.7% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.6% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.1% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.7% | 18.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
‡ 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.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 28% 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 | not 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 SNF | not 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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 discharge | not 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 stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | not 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
How full it usually is: this home is certified for 45 beds and averages 33.5 residents a day — about 74% occupied, or roughly 12 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 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 2.65 hrs/resident/day on weekends vs 3.29 on weekdays — 19% thinner on weekends. RN hours go from 0.49 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below 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 more than at the previous inspection — worsening. 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · F2025-09-04 · 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 26 residents and one main kitchen. Based on observation and interview, the facility failed to store and prepare food under sanitary conditions for the residents of the facility. This deficient practice put the residents of the facility at risk for illnesses related to food borne bacteria. Findings included:- On 09/02/25 at 09:17 AM, observations during the initial kitchen tour with Dietary Staff BB revealed the following concerns: The handwashing sinks had brown stains and grime buildup around the sink's inner and outer edges, surrounding the sink's bowl.The foot-operated trash can had a broken lid lying on the floor behind the trash can, in a pile of used coffee grounds. The open trash can was adjacent to the food preparation area, beside the steam table and a rack of clean dishes. Dietary Staff BB agreed that the food preparation area should have the trash contained to ensure food sanitation and contamination from bacteria.On 09/03/25 at 11:20 AM, during a kitchen follow-up tour with Dietary Staff BB, observations revealed the uncovered trash can…
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 · F2025-09-04 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 26 residents. Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility outside kitchen access hallway and laundry area. This created the risk for impaired safety and cleanliness. Findings included:- On 09/02/25 at 09:17 AM, a tour of the facility's kitchen area with Dietary Staff BB revealed a hallway leading from the kitchen to outside with multiple broken tiles and standing water on the floor, which was being tracked through the kitchen. Dietary Staff BB reported that when it rains, the water comes in the entrance hallway to the kitchen and must be mopped up to keep the water out of the kitchen. She confirmed the hallway was used by kitchen staff to take the trash out, and the broken tile prevented sanitation of the area. On 09/04/25 at 07:58 AM, Maintenance Staff U confirmed multiple broken tiles in the hallway outside the kitchen, which led to the outside. He stated he did not realize the broken and missing tiles existed.…
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 · E2025-09-04 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 26 residents; the sample included 14 residents. Based on interviews, record review and observation, the facility failed to ensure a safe, clean home-like environment in the resident's rooms and common areas. This deficient practice placed the residents at risk for tripping hazards, electrical accidents, respiratory hazards and decreased comfort. Findings included:- During an observation on 09/02/25 at 12:23 PM, there were multiple dark spots on the floor at the head of R15's bed, and molding was missing from the base of the wall next to the bathroom door, with exposed and broken drywall. There were damaged ceiling areas with exposed sheet rock, and the floor was dirty and stained.Observed on 09/02/25 at 11:22 AM, R30's had a large area of wall next to the resident's bed with exposed dry-wall, and paint was missing that was approximately a quarter of the wall; the floor was dirty and sticky.Observed on 09/02/25 at 11:25 AM, the north hallway floor and north hallway rooms 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 · E2025-09-04 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. Twenty-six medications were observed for medication administration accuracy. Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than five percent (%) when staff administered four medications in error resulting in a medication error rate of 17%. This placed the residents at risk of ineffective medication regimens. Findings included:- Resident (R) 12's Electronic Medical Record (EMR) included the following orders:Carafate oral tablet, 1.0-gram (gm) (Sucralfate- an anti-ulcer medication with potential to alter the absorption of some drugs), give 1.0 gm, by mouth before meals for GERD; dissolve tablet in liquid of choice, give 30 minutes before meals, ordered 0/15/25.Zofran oral tablet 4 MG/ (Ondansetron- medication to relieve nausea), give one tablet by mouth, before meals for nausea/vomiting (N/V) with meals, ordered 08/16/25.Lactulose (synthetic sugar used to treat constipation) oral solution, 20 grams/30 milliliters (ml). Give 30 ml by mouth every 24 hours as needed 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 · E2025-09-04 · tag F0924 — patternPut firmly secured handrails on each side of hallways.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 26 residents. Based on observation, interview and record review the facility failed to provide a safe and functional handrails in one of two hallways. This placed the residents at risk of impaired safety. Findings included:- Observed on 09/04/25 at 10:20 AM, during the facility tour with Maintenance Staff U, numerous handrails in the north resident hallway were loose and easily moved by hand.During an interview on 09/04/25 at 10:30 AM, Maintenance Staff U stated that he was unaware that there were loose handrails.During an interview on 09/04/25 at 10:38 AM, Administrative Staff A stated that she was unaware that there were loose handrails anywhere in the facility. She further stated that she expected staff to be vigilant and place a work order whenever they noticed any damaged equipment or when environmental repairs were needed.The facility policy Environment-General Cleanliness and Maintenance, dated 08/2024, documented that staff of the facility would provide a safe, clean, comfortable, and homelike environment, allowing each resident to use…
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 · D2025-09-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 26 residents; the sample included 14 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 3, R4, R23 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. These practices had the potential to lead to uninformed decisions regarding treatment. Findings included:- Review of the Electronic Health Record (EHR) for R3 included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), cerebral edema (abnormal buildup of fluid in the brain, causing it to swell and increasing pressure inside the skull), and adjustment disorder with anxiety (a mental health condition characterized by excessive worry, nervousness, and fear in response to a stressful life event). R3’s Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score 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.
- Potential for harm · D2025-09-04 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 26 residents; the sample included 14 residents. Based on observation, record review, and interviews, the facility failed to include Resident (R) 1 or her representative in the development and planning of the resident's care plan. This deficient practice placed R1 at risk of impaired care and decreased autonomy. Findings included:- R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychotic disturbance (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, thoughts, and behaviors), mood disturbance (psychiatric conditions characterized by persistent and intense changes in emotional state, such as prolonged sadness, irritability, or mania, leading to a decreased quality of life and potential functional impairment), and anxiety (mental or emotional reaction characterized by apprehension,…
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 · D2025-09-04 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 26 residents; the sample included 14 residents, with five sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure a14-day stop date or justification for the continuation of an as needed (PRN) psychotropic medication (alters mood or thought) including a specified duration for Resident (R)3. This deficient practice placed R3 at risk of unnecessary psychotropic medication and related adverse effects. Findings included:- Review of the Electronic Health Record (EHR) for R3 included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), cerebral edema (abnormal buildup of fluid in the brain, causing it to swell and increasing pressure inside the skull), and adjustment disorder with anxiety (a mental health condition characterized by excessive worry, nervousness, and fear in response to a stressful life…
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 · D2025-09-04 · 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 26 residents. The sample included 14 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to notify the Ombudsman of Resident (R)23's admission to the hospital, placing the resident at risk of impaired rights related to transfers and discharge. Findings included:- R23's Electronic Medical Record (EMR) included the following diagnoses: Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R23's EMR documented in the progress notes that the resident transferred to the hospital on [DATE]. R23's EMR lacked documentation of the Ombudsman being notified 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.
- Potential for harm · D2025-09-04 · 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
The facility reported a census of 26 residents. The sample of 14 residents included three residents reviewed for nutrition. Based on observation, interview, and record review, the facility failed to provide ongoing assessment by the Registered Dietician (RD) for the effectiveness of interventions and impact of nausea and vomiting on nutritional status for Resident (R)12, who had experienced a significant weight loss and continued with insidious loss. This deficient practice placed the resident at risk for continued weight loss and malnutrition. Findings included:- R12's Electronic Health Records (EHR) Physician Orders (POS), dated 08/04/ 25 documented: diagnoses which included multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), spastic hemiplegia (paralysis of one side of the body) affecting right dominant side, cerebral infarct (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), neuroleptic induced Parkinsonism (drug induced…
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 · Dcited before2025-09-04 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 26 residents. The sample of 14 residents included one resident reviewed for pain management. Based on observation, interview, and record review the facility failed to provide adequate pain management for Resident (R) 12 when staff failed to administer scheduled pain medication separate from medication that interfered with the absorption and therapeutic effectiveness of her pain medication. This placed the resident at risk for uncontrolled pain and decreased quality of life. Findings included:- R12's Electronic Health Records (EHR) Physician Orders (POS), dated 08/04/ 25 documented: diagnoses which included multiple sclerosis (MS- a progressive disease of the nerve fibers of the brain and spinal cord), spastic hemiplegia (paralysis of one side of the body) affecting right dominant side, cerebral infarct (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), neuroleptic induced Parkinsonism (drug induced parkinsonism), Schmorl's Nodes of the thoracic…
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 · D2025-09-04 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 26 residents. The sample included 14 residents which included six residents for unnecessary medications. Based on observation, interviews, and record review, the facility failed to acknowledge and/or act on the consultant pharmacist's (CP) recommendation to resolve identified irregularities for Resident (R)10, related to anticoagulant (inhibits the blood from clotting) medication. This placed R10 at risk for unnecessary medications and related complications. Findings included:- R10's Physician Orders, dated 08/06/25, revealed diagnoses which included hypertension (HTN-high blood pressure), chronic kidney disease, hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).R10's Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score 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.
- Potential for harm · Dcited before2025-09-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
The facility census totaled 26 residents on two halls. Based on observation, interview, and record review, the facility failed to ensure the staff had properly secured storage of resident medications. This deficient practice placed the residents at risk of missing medications and ineffective medication regimens. Findings included:- Observed on 09/04/25 at 10:13 AM, in the Environmental Services closet, delivery boxes sat on the floor. One box contained the following stock medications: A&D Ointment (a moisturizing cream for skin), two bottles of 81 milligram (MG) aspirin (ASA- a nonsteroidal anti-inflammatory drug [NSAID] used to treat pain, fever, and inflammation, and also used at low doses to prevent heart attacks and strokes), folic acid 1000 micrograms (MCG) (a B-vitamin that helps the body make new cells), probiotic (stimulates the growth of gut normal flora), Voltaren Gel (type of NSAID that treats joint pain caused by arthritis), Allegra 180 MG 24 hour (a medication that treats and prevents symptoms of allergies), Niacin 500 MG (vitamin B3, a water-soluble vitamin that is…
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 · D2024-01-04 · 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 32 residents with 12 residents sampled, including one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to the one sampled Resident (R)14, while staff provided cares in his room. Findings included: - Review of Resident (R)14's Physician Order Sheet (POS), dated 12/12/23, documented the following diagnoses: morbid obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions) and benign prostatic hyperplasia (BPH-a condition in which the flow of urine is blocked due to the enlargement of prostate gland causing an increase in frequency of urination at night and difficulty in urinating). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He had an indwelling urinary…
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 · D2024-01-04 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 32 residents with 12 selected for review which included one resident reviewed for Advance Directives (legal documents that provide instructions for medical care). Based on interview and record review, the facility failed to ensure one Resident (R)6's request for full resuscitative measures in case of cardiac or respiratory arrest was communicated in the care plan and to the hospice provider. Findings included: - Review of Resident (R)6's medical record, revealed diagnosis included chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and psychotic disorder (any major mental disorder characterized by a gross impairment in reality…
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 · D2024-01-04 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 32 residents with 12 residents sampled, including two residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide the two Residents (R)14 and R 20 and/or their representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the residents' transfer to the hospital. Findings included: - Review of Resident (R)14's Physician's Order Sheet (POS), dated 12/12/23, documented a diagnosis of constipation (inability to pass stool). The Significant Change Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He had no impairment in functional range of motion (ROM) and was always continent of bowel. The Urinary Incontinence/Indwelling Urinary Catheter Care Area Assessment (CAA), dated 12/27/23, documented the resident required staff assistance with toileting due to requiring assistance to get him onto…
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 · D2024-01-04 · 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 32 residents with 12 selected for review. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for two of the 12 residents reviewed. Resident (R)7 for non-pharmaceutical interventions for pain, and R6 for revision of resuscitation preferences. Findings included: - Review of Resident (R)6's medical record, revealed diagnosis included chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and psychotic disorder (any major mental disorder characterized by a gross impairment in reality testing). The Significant Change Minimum Data Set(MDS), dated [DATE], assessed the resident with a…
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 before2024-01-04 · 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 32 residents with 12 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plan for two sampled Residents (R)14, regarding failure to revise the care plan to include constipation and R7 regarding failure to revise the care plan to include aphasia communication. Findings included: - Review of Resident (R)14's Physician Order Sheet (POS), dated 12/12/23, documented a diagnosis of constipation (the inability to pass stool). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He was always continent of bowel and had constipation present during the assessment lookback period. The Urinary Incontinence/Indwelling Urinary Catheter Care Area Assessment (CAA), dated 12/27/23, documented the resident required staff assistance with getting onto and off from the bed pan for bowel movements…
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 · D2024-01-04 · 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 32 residents with 12 selected for review which included two residents reviewed for hygiene needs. Based on observation, interview and record review, the facility failed to ensure one Resident (R)7 of the two residents received assistance for grooming. Findings included: - Review of Resident (R)7's Physician Order Sheet, dated 12/12/23, revealed diagnoses that included hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness on one side of the body) due to cerebral vascular accident (stroke), and aphasia (a condition of disordered or absent language function). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13 (13-15 normal cognitive function. The resident had impairment in functional range of motion on one side of the upper and lower extremities and required maximal assistance for bathing. The Quarterly MDS, dated 11/07/23, assessed the resident had unclear speech and 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 before2024-01-04 · 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 identified a census of 32 residents, with 12 residents sampled, including two residents reviewed for constipation. Based on record review, interview and observation, the facility failed to ensure one Resident (R)14 received as needed (PRN) medications to treat constipation (the inability to pass stool), when needed in a timely manner. Findings included: - Review of Resident (R)14's Physician Order Sheet (POS), dated 12/12/23, documented a diagnosis of constipation (the inability to pass stool). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He was always continent of bowel and had constipation present during the assessment lookback period. The Urinary Incontinence/Indwelling Urinary Catheter Care Area Assessment (CAA), dated 12/27/23, documented the resident required staff assistance with getting onto and off from the bed pan for bowel movements (BM)s. The Annual MDS, 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 before2024-01-04 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such 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 reported a census of 32 residents with 12 residents sampled, including two residents reviewed for pain. Based on observation, interview and record review, the facility failed to offer non-pharmaceutical interventions for pain for one Resident (R)14, who has chronic pain. Findings included: - Review of Resident (R)14's Physicians Order Sheet (POS), dated 12/12/23, documented the following diagnoses: constipation (the inability to pass stool) and pain (physical suffering or discomfort caused by illness or injury). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He received scheduled and as needed (PRN) pain medications. No non-pharmaceutical pain interventions for pain were attempted. The resident reported regular pain which affected his sleep, day to day activities and the pain interfered with his therapy activities. The resident reported the worse pain in the past five days…
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 before2024-01-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
The facility reported a census of 32 residents with 12 selected for review. Based on interview and record review the facility failed to ensure safe storage of antianxiety medication as required. Findings included: - On 09/15/21 the physician instructed staff to administer Alprazolam (an antianxiety medication) 0.25 milligrams (mg), twice a day, for anxiety to Resident (R)6. On 05/10/23 the physician instructed staff to administer Alprazolam 0.5 mg every 12 hours as needed for anxiety or restlessness to R9. On 11/01/21 the physician instructed staff to administer Melatonin (a natural hormone that may promote sleep)5 mg, every night, for sleep to R9. Interview, on 01/03/24 at 04:13 PM, with Administrative Nurse D, revealed she investigated an incident with controlled substance, Alprazolam that occurred on 08/13/23. The medications for residents are dispensed by the pharmacy in a bubble card, with each dose separate and enclosed in a plastic bubble. Administrative Nurse D revealed on 08/12/23, Licensed Nurse (LN)H administered bedtime medications to R9. LN H placed a dose of Melatonin…
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 before2024-01-04 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
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 32 residents with 12 selected for review which included two residents reviewed for rehabilitation services. Based on observation, interview and record review, the facility failed to ensure rehabilitative services were obtained for one Resident (R)7 of the two residents reviewed for rehabilitation services. Findings included: - Review of Resident (R)7's Physician Order Sheet, dated 12/12/23, revealed diagnoses that included hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness on one side of the body) due to cerebral vascular accident (stroke), and aphasia (a condition of disordered or absent language function). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13 (13-15 normal cognitive function) and the resident had clear speech. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/17/23, assessed the resident had a…
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 before2023-07-12 · 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 32 residents with 13 residents sampled for review. Based on observation, interview and record review, the facility failed to review and revise the plan of care to include appropriate interventions following a fall and failed to provide interventeions for safe transfers for one dependent Resident (R)5. Findings included: - The Physician Order Sheet (POS), dated 06/10/23, for Resident (R)5, documented a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She required limited assistance of one staff for ambulation in the corridor and locomotion in the facility and limited assistance of two staff for transfers. Her balance was not steady, but she was able to stabilize with staff assistance. She had one fall with major injury since 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 before2023-07-12 · 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 32 residents with 16 selected for review. The sample included two residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to notify Resident (R)135's physician of an allegation of abuse. Findings included: - Review of R135's Physician Order Sheet, dated 06/02/23, revealed the following diagnoses: macular degeneration (progressive deterioration of the retina) schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and major mood disorder. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with intact cognitive function. The resident had verbal behavioral symptoms directed toward others one to three days during the seven days look back period. The resident was independent with activities of daily living. The Behavioral Symptoms Care Area Assessment (CAA), dated 11/16/22, documented the resident heard voices and yelled 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 · D2023-07-12 · 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 32 residents with 13 residents sampled, including five residents reviewed for accidents. Based on observation, interview and record review, the facility failed to implement appropriate interventions for a fall and failed to provide safe transfers for one dependent Resident (R)5. Findings included: - The Physician Order Sheet (POS), dated 06/10/23, for Resident (R)5, documented a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She required limited assistance of one staff for ambulation in the corridor and locomotion in the facility and limited assistance of two staff for transfers. Her balance was not steady, but she was able to stabilize with staff assistance. She had one fall with major injury since the prior assessment. 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 · D2023-07-12 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 32 residents with 13 residents sampled, including six residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to keep one Resident (R) 27 free from unnecessary medications to ensure no adverse effects/consequences. Findings included: - Review of R)27's electronic medical record (EMR), revealed a diagnosis of hypothyroidism (condition characterized by decreased activity of the thyroid gland). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She had no rejection of care. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), documented staff were to monitor and report any decline. The quarterly MDS, dated 06/14/23, documented the resident had a BIMS score of 15, indicating intact cognition. She had no rejection of care. The care plan, revised 07/05/23, 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.
- Potential for harm · Dcited before2023-07-12 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
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 32 residents with 13 residents sampled, including one resident reviewed for rehabilitation services. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)31 received physical therapy, as ordered by the physician. Findings included: - The Physician Order Sheet (POS), dated 05/02/23, documented Resident (R)31 had a diagnosis of acute kidney failure (when kidneys suddenly become unable to filter waste products from your blood). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident did not receive therapy during the assessment period. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/22/23, documented the resident required staff assistance with ADLs when feeling weak. The Quarterly MDS, dated 04/28/23, documented the resident had a BIMS score of 15,…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to ADVENA LIVING COMMUNITIES — 6 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 | 1 of 5 | 1.3 | -0.3 vs chain |
| Health inspection | 2 of 5 | 1.5 | +0.5 vs chain |
| Staffing | 3 of 5 | 2.0 | +1.0 vs chain |
| Quality measures | 1 of 5 | 1.7 | -0.7 vs chain |
The other 5 homes this chain runs (chain average 1.3★, 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 | Since |
|---|---|---|---|
| CGHII INC | Organization | DIRECT OWNERSHIP INTEREST | since 09/01/2018 |
| PATTERSON, BERNIECE | Individual | DIRECT OWNERSHIP INTEREST | since 07/01/2024 |
| CORNERSTONE GROUP HOLDINGS INC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/01/2018 |
| NOVOTNY, MICHELLE | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2018 |
| NOVOTNY, WILLIAM | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2018 |
| NEW PARADIGM SOLUTIONS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/12/2025 |
| PRESTON, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2022 |
| STACY, SKYLAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/14/2025 |
| CORNERSTONE EMPLOYMENT SOLUTIONS INC | Organization | ADP OF THE SNF | since 09/01/2018 |
CMS files one row per role, so the 17 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 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.
About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $193K 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 175335. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, 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 →
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