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Medicalodges Coffeyville On Midland

2921 W 1st Street, Coffeyville, KS 67337 · For profit - Corporation · 100 certified beds · (620) 251-5190 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0609, F0610) — most recent Sep 2024Resident-funds citations (F0565, F0567, F0568, F0569)1 immediate-jeopardy citation3 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$217,665 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0609, F0610) — most recent Sep 2024
  • it has citations for mishandling residents’ money or property (F0565, F0567, F0568, F0569)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 3 serious findings 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 (43) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $217,665 in federal fines (most recent 2026-04-09)
  • 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1400 W 4th St · (620) 251-0777 · Call to confirm hours
Pharmacy
1205 W 8th St · (620) 251-3533 · Call to confirm hours
Grocery
1000 Hall St · (620) 251-6820 · Call to confirm hours
Park
(620) 252-6100 · Typically dawn to dusk
Place of worship

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 4 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 improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.9%17.9%15.4%worse
Long-stay residents who lose too much weight7.7%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder1.7%1.6%0.9%worse
Long-stay residents with a urinary tract infection3.5%2.9%2.0%worse
Long-stay residents with depressive symptoms0.0%6.5%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.6%4.3%3.3%worse
Long-stay residents whose ability to walk worsened15.8%16.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication39.9%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine90.4%95.5%95.3%typical
Long-stay residents with pressure ulcers5.4%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control28.9%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.6%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.9%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine66.7%73.8%79.4%worse
Short-stay residents rehospitalized after admission24.6%22.4%22.6%typical
Short-stay residents with an outpatient ER visit10.5%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.621.801.67worse
Long-stay outpatient ER visits per 1,000 resident days3.142.131.80worse

* 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.

60.2% 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 132 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.2%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
75.9%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 75.9% 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 54 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF60.2%CMS range 52.4–66.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.5–14.110.7%Oct 2022–Sep 2024no 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 discharge75.9%56.6%Oct 2024–Sep 2025CMS 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 discharge57.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge79.6%50.0%Oct 2024–Sep 2025CMS 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 identified93.8%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.6%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 3.5–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 2022–Sep 2024CMS 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

0.71
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.58
Aide hours/ resident / day
4.17
Total nurse hours/ resident / day
0.59
RN hoursweekends
43.0%
Total nursing turnover
18.2%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 68.3 residents a day — about 68% occupied, or roughly 32 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 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 3.68 hrs/resident/day on weekends vs 4.36 on weekdays — 16% thinner on weekends. RN hours go from 0.76 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

10
deficiencies at the latest standard inspection (2026-04-09)
12
at the previous standard inspection (2024-05-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

43 citations, most serious first. The 16 most serious are shown; the remaining 27 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-09-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 72 residents with four residents sampled and one resident reviewed for neglect. Based on observation, interview, and record review, the facility failed to prevent the neglect of cognitively impaired Resident (R)2, who displayed a recent increase in behaviors. On 08/26/24 at 10:12 PM, Licensed Nurse (LN) G completed a skin assessment on R2 and documented her skin as clean, dry, intact, and without new skin conditions. On 08/27/24 at 10:45 AM, staff observed blood on a tissue after wiping R2 and failed to notify the LN in charge of R2's care. On 08/27/24 at 11:15 AM, Social Service Staff X and Administrative Staff B took R2 out of town to a senior behavioral unit. Upon arrival to the emergency room, R2 expressed the need to use the bathroom and when assisted by facility staff, R2's brief had two dime size spots of blood in it, and she had blood at the front of her peri-area. On 08/27/24 at 02:45 PM, hospital staff began a skin assessment on R2 after she arrived at the behavioral…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2024-08-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 99 residents with three residents sampled and one resident reviewed for abuse. Based on observation, interview, and record review, the facility failed to prevent the verbal and physical abuse of cognitively impaired Resident (R) 2 on 07/13/24 and again on 07/19/24. On 07/13/24, Non-Certified Staff N observed Certified Nurse Aide (CNA) O grab R2's arms near her wrists and pushed them to R2's chest. CNA O then stated to R2, You are [explicit language] with the wrong person. I will hit you back. CNA O then turned and walked away. Non-certified Staff N failed to report her observation immediately and CNA O continued to work her scheduled shift and additional shifts following 07/13/24. On 07/19/24, CNA M was in the hallway and heard CNA O and R2 yelling back and forth from R2's room. CNA M went to assist and saw R2 attempt to hit CNA O, and CNA O grabbed R2's arms and put them forcefully against R2's chest. CNA O stated to R2, You chose the right [explicit language] one, you will not…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Jcited before2024-08-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 99 residents with three residents sampled and one resident reviewed for abuse. Based on observation, interview, and record review, the facility failed to immediately report incidents of verbal and physical abuse of cognitively impaired Resident (R) 2 on 07/13/24 and again on 07/19/24. On 07/13/24, Non-Certified Staff N observed Certified Nurse Aide (CNA) O grab R2's arms near her wrists and pushed them to R2's chest. CNA O then stated to R2, You are [explicit language] with the wrong person. I will hit you back. CNA O then turned and walked away. Non-certified Staff N failed to report her observation immediately and CNA O continued to work her scheduled shift and additional shifts following 07/13/24. On 07/19/24, CNA M was in the hallway and heard CNA O and R2 yelling back and forth from R2's room. CNA M went to assist and saw R2 attempt to hit CNA O, and CNA O grabbed R2's arms and put them forcefully against R2's chest. CNA O stated to R2, You chose the right [explicit…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2024-08-14 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 99 residents with three residents sampled and one resident reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure the staff protected residents from abuse when staff did not immediately report incidents of verbal and physical abuse of cognitively impaired Resident (R) 2 on 07/13/24 and again on 07/19/24. On 07/13/24, Non-Certified Staff N observed Certified Nurse Aide (CNA) O grab R2's arms near her wrists and pushed them to R2's chest. CNA O then stated to R2, You are [explicit language] with the wrong person. I will hit you back. CNA O then turned and walked away. Non-certified Staff N failed to report her observation immediately and CNA O continued to work her scheduled shift and additional shifts following 07/13/24. On 07/19/24, CNA M was in the hallway and heard CNA O and R2 yelling back and forth from R2's room. CNA M went to assist and saw R2 attempt to hit CNA O, and CNA O grabbed R2's arms and put them forcefully against…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2024-05-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 81 residents, with 20 in the sample, and two residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to ensure pertinent and timely interventions were implemented as ordered to prevent Resident (R)13's significant weight loss of 25.11 percent (%) in 141 days. The facility did not weigh R13 monthly and did not identify and assess R13 when meal intake consistently declined between 10/2023 and 02/2024. This failure resulted in a R13 losing 29.4 pounds (lbs.)/25.11% body weight, in 141 days. Additionally, the facility failed to monitor R13 for effectiveness of their treatment plan which resulted in an additional weight loss of 11.2 lbs in an additional 42 days which was a total of 40.6 lbs/29.64% over 182 days and placed the resident at risk for continued decline in nutritional status and at risk for the development of life-threatening symptoms, which could negatively affect the mental, physical, and psychosocial well-being of R13.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2022-07-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 89 residents with 20 selected for review including three residents reviewed for pressure ulcers. (localized injury to the skin and/or underlying tissue usually over a bony prominence, as result of pressure, or pressure in combination with shear and/or friction) Based on observation, record review, and interview, the facility failed to prevent the development of and promote healing of a pressure ulcer diagnosed as a stage three (full thickness loss of skin usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R)41. In addition, the facility failed to perform a dressing change with sanitary conditions related to infection control. Furthermore, the facility failed to prevent the development of and promote healing of three pressure areas diagnosed as a stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without sloughing or bruising and may also present as an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-09 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included:- Review of employee files on 04/08/26 at 03:52 PM revealed a lack of performance evaluations or skills check-off for two Certified Nurse Aides (CNAs), CNA OO and CNA PP. CNA OO had a date of hire of 11/10/23, and CNA PP had a date of hire of 07/29/24. On 04/08/26 PM, Administrative Staff A and Administrative Nurse D confirmed the employee evaluation documents provided to the survey team did not contain performance evaluations for CNA OO and CNA PP. Administrative Staff A stated she expected performance evaluations to be performed annually. The facility did not provide a policy related to annual performance evaluations as requested on 04/09/26.

    Nursing and Physician Services Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Fcited before2026-04-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to store and prepare food in the kitchen under sanitary conditions which placed the residents of the facility at risk for food borne illnesses. Findings included:- The initial tour of South Kitchen on 04/06/2026 at 08:44 AM, with Dietary Staff DD identified the following concerns:A handwashing sink and backsplash area had grime build-up.One double-door freezer lacked an internal thermometer. The Resource Refrigerator/Freezer Temperature Log signage on the freezer door included the temperature recorded for 04/06/26 as 20 degrees Fahrenheit (F) by Dietary Staff DD. Grime build-up in the alcove of the kitchen along the baseboard.Dry storage with bread unsealed and unlabeled.Refrigerator with two unsealed and unlabeled ham spread sandwiches.Two unlabeled salad dressing bottles.Unlabeled container of pancake batter with congealed white batter on the outside of the container.Unlabeled and unsealed bread/buns bag with two buns missing.Sanitizing strips are unavailable in the south kitchen upon request.Two unlabeled bags of potato…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2026-04-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate activity of daily living (ADL) cares to Resident (R)39 regarding an unshaven face, dried food on face and jagged, dirty fingernails; R6 regarding an unshaven face; R44 regarding an unshaven face and dirty clothing and R51 regarding jagged, dirty fingernails. Findings included:- R6's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R6's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He required substantial to maximal staff assistance for showering and personal hygiene. R6's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 10/24/25, documented the resident required substantial assistance of staff for bathing and personal hygiene. R6's Quarterly MDS, dated [DATE], documented the resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · E2026-04-09 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a resident specific activity program for Resident (R)4, R6, R39, R44, and R51. Findings included:- R4's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R4's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. It was very important for her to listen to music she liked, participate in her favorite activities, participate in religious services, and go outside to get fresh air when the weather was good. R4's Activity Care Area Assessment (CAA), dated 12/18/25, did not trigger. R4's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 99, indicating severe cognitive impairment. R4's Care Plan, revised 03/26/26, lacked staff instruction on the residents' preferred activities. R4's Activity Assessment,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-04-09 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide privacy for Resident (R)4, while she was in her room in bed. Findings included:- R4's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R4's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She was dependent on staff for all Activities of Daily Living (ADL). R4's ADL Care Area Assessment (CAA), dated 12/18/25, did not trigger. R4's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She was dependent on staff for all ADLs. R4's Care Plan, revised 03/26/26, instructed staff she was dependent on staff for all ADLs. On 04/06/26 at 10:03 AM, the resident rested in her bed, covered with blankets, and the door to her room was open to the hallway. R39 wandered into R4's room and began to move around 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.

    Resident Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-04-09 · tag F0628 — isolated
    Provide 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 Based on interview and record review, the facility failed to provide Resident (R) 3, and R7 a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. Findings included: - R3's Electronic Health Record (EHR) documented diagnoses that included dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) R3's Discharge – Return Anticipated Minimum Data Set (MDS) dated [DATE] documented R1 had an unplanned discharge from the facility to a hospital on [DATE]. The EHR Progress Notes documented: On 01/11/26 at 05:42 PM, a Nurse's Note documented R3 was admitted to the hospital with a right hip fracture (broken bone) On 01/12/26 at 01:17 PM, a Social Service Progress Note documented the care plan meeting scheduled for the next day was cancelled due to the resident being in the hospital.…

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

    Resident Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 Based on observation, interviews and record reviews, the facility failed to ensure adequate catheter care within the standards of practice was provided for Resident (R) 59 when staff failed to secure the catheter tubing to R59's thigh to prevent pulling and/or dislodgement and also failed to empty the catheter bag before getting too full, to prevent catheter-related urinary tract infections (UTI). Findings included:- R59's Electronic Medical Record (EMR) from the Diagnosis tab documented Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), chronic kidney disease-stage three (CKD), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), atrial fibrillation (rapid, irregular heartbeat), obstructive uropathy, neurogenic bladder and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-04-09 · tag F0697 — failed to manage pain — isolated
    Provide 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 Based on observation, interview and record review, the facility failed to offer non-pharmaceutical interventions for pain for one Resident (R)3, who had acute pain. Findings included:- R3's Electronic Medical Record (EMR) documented a diagnosis of a wedge compression fracture (a type of spinal fracture where the front of a vertebra collapses while the back remains intact) of the second lumbar vertebra. R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She received as-needed (PRN) pain medications and non-medication pain interventions during the assessment period. Pain was not assessed. She received opioid (narcotic pain medication) medication during the seven-day look-back period. The Pain Care Area Assessment (CAA), dated 01/19/26, did not trigger. The re-admission MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to maintain an effective infection control program related to the Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing care. The facility also failed to store respiratory treatment devices in a sanitary manner. Findings included:- Observation on 04/06/26 10:36 AM, R20 oxygen tubing was wound around the portable oxygen tank. R20's nebulizer mouthpiece was attached to the medication bowl with a small amount of fluid in the medication bowl and attached to the nebulizer machine. On 04/08/26 at 10:35 AM, R1's nebulizer machine was attached to the face mask with the medication bowl attached with fluid in it. It laid on her chair beside her bed with the tubing wound up with a blacket, and her back brace laid on top of the nebulizer. An observation of catheter care was conducted on 04/08/2026 at 10:37 AM with Certified Nursing Assistant (CNA) II and CNA Q assisting R59 with…

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

    Infection Control Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Fcited before2024-05-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 81 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. Findings included: - During an initial tour of the kitchen, on 05/07/24 at 10:55 AM, the following areas of concern were noted: The hand-washing sink trashcan lacked a cover. The refrigerator contained 11 dressing cups which were unlabeled. Three gelatin parfaits which were unlabeled. A gallon container of peach slices, dated 05/01/24, was not properly covered. A bag of 12 baked potatoes, which were unlabeled. Three of the racks in the refrigerator contained dried-on food substances and rust. The outside dumpster contained garbage bags and was not closed. A five-gallon container of flour contained grime on top of the lid. A five-gallon container of dried milk contained grime on top of the lid. On 05/07/24 at 11:28 AM, Dietary Consultant E verified the above issues. The facility lacked a policy for the kitchen. The…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 27 citations
  • Potential for harm · Fcited before2024-05-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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 81 residents. Based on observation and interview, the facility failed to ensure staff performed hand hygiene during meals, failed to ensure sanitary storage of oxygen concentrators with tubing, failed to ensure staff performed hand hygiene during dressing change, failed to ensure sanitary glucometer cleaning for two glucometers used by three residents, and failed to ensure staff provided enhanced barrier precautions for two Residents (R) 5 and R22 with the use of urinary catheters. Findings included: - Observation, on 05/08/24 at 12:37 PM, revealed Certified Nurse Aide (CNA) U assisted Residents (R) 61 and R3 with their noon meal. CNA U positioned the pedals of R61's wheelchair and placed her feet upon them, then without performing hand hygiene, picked up a glass of fluid, handled the straw in the glass and offered it to R3. CNA U removed R3's clothing protector, wiped her mouth with her napkin, placed the napkin in the soiled linen bin, then without performing hand hygiene, repositioned R61 in her chair and assisted her out of the dining room.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-13 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 81 residents. Based on observation, interview, and record review the facility failed to ensure the resident had a right to organize and participate in resident groups in the facility, respond to written requests that resulted from group meetings, consider the views of a resident or family group, and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Additionally, the facility failed to demonstrate their response and rationale for such response to resident's concerns voiced in resident council. Findings included: - During an interview with Resident (R) 5 on 05/07/24 at 03:27 PM, he reported food could be better and he noted the facility would run out of food. R5 reported the food was cold at times and he just ate it, but sometimes would get aggravated and send it back. The facility did do not always have a cook for grill orders in the event residents did not want what was on the main menu. R5 reported the facility had a lot of changes in the kitchen. He stated he reported…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-13 · tag F0568 — pattern
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 81 residents, which included 31 residents with active trusts held by the facility. Based on observations, interviews, and record review, the facility failed to provide quarterly statements for the 31 residents in facility. The facility further failed to establish and maintain a system that assured a full complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. Findings included: - Review of trust transaction history of all 31 residents identified that there were no copies of the quarterly statement available to review. On 05/09/24 at 02:36 PM, Administrative Staff O stated it was the facility's policy to offer trust statements quarterly based on the calendar year. Administrative O stated she has been at this post for a little over a week and was not sure what the previous business office manager did. Administrative Staff O stated she normally printed off three copies of the resident statements and sent two to the representative…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-13 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 81 residents. Based on observation, interview, and record review the facility failed to ensure residents had a right to voice grievances with respect to care and treatment, the behavior of staff, other residents, and other concerns regarding their long-term care stay. Additionally, the facility failed to make prompt efforts resolve the grievances the residents had and provide a written decision regarding his or her grievance. Findings included: - During an interview with Resident (R) 5 on 05/07/24 at 03:27 PM, he reported food could be better and he noted the facility would run out of food. R5 reported the food was cold at times and he just ate it, but sometimes would get aggravated and send it back. The facility did not have a cook for grill orders in the event residents did not want what was on the main menu. R5 reported the facility had a lot of changes in the kitchen. He stated he reported his concerns to Social Service Designee (SSD) F as well as voiced his concerns in Resident Council, but nothing changed. No one from the facility would come…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-13 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 81 residents with 31 residents sampled, including seven residents reviewed for Activities of Daily Living (ADLs). Based on observation, interview, and record review, the facility failed to provide appropriate and timely ADL cares to four Residents (R) 13, R8, and R46, regarding untrimmed facial hair and R49, regarding untrimmed facial hair and long fingernails. Findings included: - Review of Resident (R) 13's electronic medical record (EMR) documented a diagnosis of type II diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. He was dependent on staff for completion of ADLs. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/17/23, documented the resident required staff assistance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-13 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 81 residents which included 31 residents with active trusts accounts, held by the facility. Based on observations, interviews, and record review, the facility failed to provide Resident (R)13 with the accurate accounting of her personal funds, when the facility overcharged the residents personal funds account by $51.00. Findings included: - Review of trust transaction fund dated 01/23/23 to 05/09/24 documented a closing balance of eleven dollars and one cent for R13. On 05/07/24 at 03:34 PM, R13's family member stated R13 should have money in the account, but the facility staff told R13 she did not have money. On 05/09/24 at 02:26 PM, Administrative Staff O stated the facility cash box in the business office contained about three hundred dollars in cash, and the cash bag locked up in the medication cart on the first unit at main entrance contained twenty-one dollar bills for afterhours resident fund access. For larger amount of money, the Administrator or Director of Nursing had access to a check book that could be used, except for on Sundays.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-13 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 81 residents. The facility identified 31 residents with active personal funds accounts. Based on observations, interviews, and record review, the facility failed ensure the conveyance of personal funds within 30 days of discharged for Resident(R) 192 and within 30 days of death for R193. Findings included: - Review of trust transaction history of all 31 residents identified with personal funds accounts revealed two residents' names which were not on the current resident census list of facility: R192 expired on [DATE] and R193 discharged from facility on [DATE]. On [DATE] at 11:06 AM, the facility provided documentation revealed a current balance of $103.38 for R193, and a current balance of $1,138.20 for R192. On [DATE] at 01:40 PM, Administrative Staff O stated they were aware of the federal requirement to disperse personal funds back to resident or family and or responsible party, 30 days after discharge. On [DATE] at 01:45 PM, Administrative Staff A reported resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 81 residents with 31 residents sampled. Based on observation, record review, and interview the facility failed to complete a comprehensive care plan for one Resident (R) 8, regarding the use of oxygen (O2). Findings included: - Review of Resident (R) 8's electronic medical record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The resident did not utilize oxygen (O2). The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/30/24, did not trigger for further review. The Care Plan, revised 04/30/24, lacked staff instruction regarding care of the O2 tank or supplies. Review of the resident's EMR…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 81 residents with 31 residents sampled, including one resident reviewed for respiratory. Based on observation, record review, and interview the facility failed to store oxygen tubing in a clean and sanitary manner for Resident (R) 8. Findings included: - Review of Resident (R) 8's electronic medical record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The resident did not utilize oxygen (O2). The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/30/24, did not trigger for further review. The Care Plan, revised 04/30/24, lacked staff instruction regarding care of the O2 tank or supplies. Review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-07-14 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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 89 residents. Based on interview and record review, the facility failed to maintain an infection prevention and control program to proactively monitor infections in the facility to ensure to help prevent the spread of infections among the residents of the facility. Findings included: - Review of the Infection Control Surveillance Logs for 2022 revealed the following irregularities: The February, March, April, May and June 2022 logs lacked infection resolution information and tracking of infections by pathogen. The June 2022 log lacked culture results for four residents with urinary tract infections. The July 2022 log was not available for review as of 07/14/22. The facility reported five residents with positive COVID-19. Interview, on 07/14/22 at 11:02 AM, with Administrative Nurse D confirmed the lack of proactive monitoring of infections in June and July except for the COVID-19 infections. Administrative Nurse D stated the facility changed ownership in May 2022 and the Infection Preventionist left employment with uncompleted infection tracking…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-07-14 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 89 residents. Based on interview and record review, the facility failed to ensure the facility nursing staff followed the principles of antibiotic stewardship in a proactive manner to ensure residents received antibiotics in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance. The facility failed to track and trend infections causative microorganisms throughout the facility and failed to compile antibiotic use data for prescribing practitioners. Findings included: - Review of the Infection Control Surveillance Logs for February, March, April, May and June 2022 logs revealed they lacked infection resolution information, tracking of infections by pathogen, and indication of adherence to McGeer's Criteria (a set of symptom criteria for determination of infections.) in determining infection presence. The February 2022 Infection Control Surveillance Log lacked culture results for two residents with urinary tract infections and treated with Levofloxacin and Augmentin respectively. The March 2022…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-07-14 · tag F0887 — widespread
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 89 residents. Based on interview and record review, the facility failed to ensure residents were offered the second vaccine booster which became available on May 20,2022 in a timely manner as required. Findings included: - Review of the unlabeled resident vaccine log, updated 04/19/22, provided by the facility, revealed a total of 76 residents still in the facility. Of these 78 residents 44 received three doses of the COVID-19 vaccine, 24 received two doses and 10 refused. Review of the electronic medical record Immunization/Vaccine tab, for each of the following residents, revealed the following: Resident (R)44 received three doses of COVID vaccine with the last dose recorded as administered on 11/18/21. R80 received three doses of COVID vaccine with last dose recorded as administered on 11/18/21. R 41 received two doses of COVID with last dose administered on 11/18/21. R49 received three doses of COVID vaccine with the last dose indicated administered as 11/18/21. The documentation lacked any indication of when next dose was due. R 78 refused but…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-14 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 89 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in the facility on two of five halls. Findings included: - An environmental tour on 07/14/22 at 09:37 AM, revealed the following concerns: 1. Three resident isolation rooms on one hall had bags of incontinent briefs resting directly on the floor outside of their rooms. 2. There were four cardboard boxes of incontinent briefs resting directly on the floor in the hallway outside the storage room. On 07/14/22 at 09:37 AM, Housekeeping/Maintenance staff AA stated the boxes had been in the hallway since 07/12/22. Staff AA stated she was unsure of who was supposed to put the boxes away in the supply room. The facility policy for Housekeeping, Laundry and Maintenance, undated, included: Storage areas and equipment rooms must be kept neat and free of extraneous materials. The facility failed to provide housekeeping and maintenance services to maintain 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-14 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 89 residents which included 20 residents sampled for review. Based on observation, interview, and record review, the facility failed to complete the Care Area Assessment (CAA analysis of findings), related to a Comprehensive Minimum Data Set (MDS), for four Residents (R)186, R137, R43, and R19, to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. Findings included: - Review of Resident (R)186's, undated Physician Orders, revealed diagnoses which included, dementia (progressive mental disorder characterized by failing memory, confusion)with behavioral disturbances, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), adult failure to thrive, constipation, personal history of transient ischemic attack (TIA-episode of cerebrovascular insufficiency), cerebral infarction (sudden death of brain cells due to lack of oxygen…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-14 · tag F0637 — pattern
    Assess the resident when there is a significant change in condition
    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 89 residents which included 20 residents sampled for review. Based on observation, interview, and record review, the facility failed to complete the Care Area Assessment (CAA-analysis of findings), related to a Significant change in Status Minimum Data Set (MDS), for four selected Residents (R)46, R 44, R 4, and R 23, as required. The residents experienced a change of condition in at least two or more activities of daily living (ADL's) with a significant change in the resident's physical or mental condition, that had an impact on more than one area of these residents health status. Findings included: - Review of Resident (R)46's, undated Physician Orders, revealed diagnoses which included infection and inflammatory reaction due to internal left hip prosthesis (left artificial hip joint), urinary tract infection, anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), diabetes mellitus (when the body cannot use glucose, not enough…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-14 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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 89 residents with 20 selected for review. Based on observation, record review, and interview, the facility failed to review and revise the care plan for six of the residents reviewed including; Resident (R)68 and R41 with pressure ulcers, R137 for bladder incontinence and skin issues, R23 and R186 with skin conditions, and R46 for bathing activity. Findings included: - The Medical Diagnosis Tab, located in the electronic medical record (EMR), for Resident (R)68, included diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion) , diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and nutritional deficiency. The Quarterly Minimum Data Set (MDS) dated [DATE], assessed R68 with having a short-term and a long-term memory problem, severely impaired decision making, and 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-14 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide 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 89 residents with 20 selected for review, which included five residents reviewed for quality of care. Based on observation, interview and record review, the facility failed to monitor non-pressure skin issues for three of the five residents (R) 137, 23 and 186 and obtaining physician ordered daily weights for two of the five residents, R 43 and R29. Findings included: - Review of Resident (R)137's Physician Order Sheet, dated 06/27/22, revealed diagnoses included urinary tract infection, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and cognitive (mental function) communication deficit. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with mild cognitive impairment, and the resident required extensive assistance of two staff for bed mobility transfer, toilet use and ambulation. The resident's balance on and off the toilet was not steady and needed staff for stabilization. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-14 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 89 residents and identified 58 residents resided on the below 2 of four resident halls. Based on observation, interview, and record review, the facility failed to ensure an accurate continued accounting system for monitoring and reconciliation of narcotic medications, to prevent misappropriation of 58 residents, identified to reside on these two of affected halls of the four resident halls of the facility. Findings included: - A narcotic count of the medication cart on one of the facility's halls, on [DATE] at 03:20 PM, revealed the following concerns: 1. The Controlled Medication Inventory (a sheet used to keep count of narcotic medications) sheets lacked nurses' signatures in multiple areas. 2. Resident (R)65's Drug Dispensing Record for Roxanol (Narcotic used to treat moderate-to-severe pain) 0.25 millileter (ml), sublingual (under the tongue), did not match the amount of medication in the bottle. The bottle of Roxanol held 12 mls of medication while the Drug Dispensing…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-14 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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 89 residents. Based on observation and interview the facility failed to provide a safe and sanitary environment for the resident's kitchen and outside area. Findings included: - The kitchen tour on 7/13/22 at 01:39 PM, with Dietary Staff BB, revealed the following concerns: 1. A countertop with approximately six inches of missing laminate which exposed particle board. 2. The concrete kitchen floor with multiple areas of missing sealant/paint throughout the kitchen and dish area floors. 3. The floor at the doorway of the entrance to the food prep and service area had two broken floor tiles. 4. The floor beneath the deep fryer, oven, and stove had areas of broken concrete and chipped sealer. 5. The sidewalk outside the kitchen back exit door,had broken uneven concrete the width of the sidewalk in route to the grease disposal and dumpster. 6. Outside of the back exit kitchen door, was a broken corner curb, in route to the dumpster. 7. The step-up metal entry to the walk-in back kitchen door had rusted out metal areas. The facility lacked a policy that…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-14 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 89 residents with 20 sampled for review, which included one resident reviewed with a urinary catheter. Based on observation, interview, and record review, the facility failed to ensure the dignity of the one sampled resident, (R) 4 with a catheter/urine collection bag, with the lack of a cover to prevent full visualization of the resident's urine by anyone present. Findings included: - Review of Resident (R)4 Physician Orders, dated 5/22/22 revealed diagnoses which included, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half 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) affecting left dominant side, and benign prostate hyperplasia without lower urinary tract symptoms (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-14 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 89 residents. The sampled of 20 residents included 2 residents for choices related to bathing. Based on observation , interview, and record review the facility failed to provide choices for two Residents (R)46 and R44 related to bathing. Findings included: - Review of the Resident (R)46's undated Physician Orders, revealed diagnoses which included, presence of left artificial hip joint, muscle weakness, and pain in bilateral (both) feet. The Significant Change in Status Minimum Data Set (MDS), dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment. She reported all areas of choice/preference in her routine were very important to her. She required extensive assistance of staff with all activities of daily living (ADLS) and she was totally dependent on staff for bathing. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/11/22, documented the resident was working with physical…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 89 residents. The sample of 20 residents included one reviewed for abuse. Based on interview and record review, the facility failed to ensure submission of an allegation of abuse investigation, for the one sampled resident (R)135, within five days as required. Findings included: - Review of resident (R)135's Physician Order Sheet, dated 05/10/22, revealed diagnoses included traumatic subdural hemorrhage (collection of blood on the surface of the brain) and unspecified dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with moderate cognitive function and no behaviors. The resident required extensive assistance of one person for bed mobility, transfer, ambulation and toilet use. The resident's balance was not steady and was able to stabilize with staff assistance. The resident had falls prior to admission. The ADL (Activity of Daily…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The census reported a census of 89 residents with 20 residents sampled, including four residents reviewed for activities of daily living (ADL)s. Based on observation, interview, and record review, the facility failed to ensure two of the four, dependent Residents (R)16 and R 41 received appropriate personal hygiene, regarding long, dirty fingernails. Findings included: - The Physician's Order Sheet (POS), dated 06/09/22, documented Resident (R)16 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. She required extensive assistance of one staff for personal hygiene. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 08/22/21, triggered but had not been completed. The quarterly MDS, dated 02/17/22, documented the resident had a BIMS score of 5, indicating severe cognitive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 89 residents with 20 selected for review, which included two residents reviewed for bowel and bladder. Based on observation, interview and record review, the facility failed to ensure one of the two residents (R)137 remained as continent as possible with unobstructed access to the bathroom. Findings included: - Review of Resident (R)137's Physician Order Sheet, dated 06/27/22, revealed diagnoses included urinary tract infection, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and cognitive (mental function) communication deficit. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with mild cognitive impairment, and required extensive assistance of two staff for bed mobility, transfer, toilet use, and ambulation. The resident's balance on and off the toilet was not steady and needed staff for stabilization. The ADL (Activity of Daily Living Functional/Rehabilitation Potential Care Area…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-14 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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

    - Review of resident (R)23's Physician Order Sheet, dated 06/17/22, revealed diagnosis included heart failure, chronic obstruction pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic stage three kidney disease. The Care Plan, reviewed 06/03/22, instructed staff the resident received medications with Black Box Warnings. Review of the Physician's Order Sheet, dated 06/27/22, instructed staff to administer the following: Start date 04/26/22, Cozaar, 25mg (milligrams), daily for hypertension (elevated blood pressure). Staff instructed staff to hold the medication if the systolic blood pressure was less than 110 mmHg (milligrams of Mercury) and to notify the physician if staff held the medication for three consecutive days. Start date 04/26/22, Isosorbide ER (extended release), 30mg, daily for hypertension. Staff instructed to hold the medication if the systolic blood pressure was less than 120 mmHG and to notify the physician if staff held the medication for three consecutive 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-04-09 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 65 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included:During the initial kitchen tour on 04/06/26 at 08:44 AM, with Dietary Staff BB, the following concerns were identified at the facility dumpster:Two used gloves lay on the ground beside the base of the dumpster.One broken metal and upholstered armchairFour cloth recliners with large black stain/substance on the fabric surface, which included one red recliner with the back pulled/broken off. A broken chest of drawers with broken shelving and top. On 04/06/26 at 08:54 AM, Dietary Staff BB confirmed the above findings and reported she was not aware of the trash and garbage accumulation around the dumpster and did not know what arrangements were made to pick up the trash and garbage. The maintenance department handled the disposal of trash, garbage, and refuse. On 04/08/26 at 02:20 PM, Maintenance staff U stated maintenance the staff were responsible for the maintenance and cleaning 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has no plan of correction
  • No harm found · C2024-05-13 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 81 residents. Based on interview and record review, the facility failed to ensure staff recorded the resident census on the Daily Staff Postings as required. Findings included: - Review of the Daily Staff Posting for February 2024, March 2024, and April 2024, revealed lack of documentation of the resident census for each day. Interview,on 05/13/24 at 10:40 AM, with Administrative Staff HH, revealed she did not document the daily resident census on the Daily staff Postings. Interview, on 05/13/24 at 11:45 AM, with Administrative Staff A, confirmed the lack of resident census on the Daily Staff Postings and lacked a policy for documentation required on the form. The facility lacked a policy for documentation required for Daily Staff Posting. The facility failed to document the daily resident census on the Daily Staff Posting as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$217,665 in federal fines across 5 penalties.

  • $54,084 — penalty dated 2026-04-09
  • $84,124 — penalty dated 2024-09-09
  • $24,065 — penalty dated 2024-08-14
  • $24,065 — penalty dated 2024-08-14
  • $31,327 — penalty dated 2024-05-13

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 MEDICALODGES, INC. — 18 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.7+0.3 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 5 of 53.6+1.4 vs chain
Quality measures 2 of 52.8-0.8 vs chain
The other 17 homes this chain runs (chain average 2.7★, 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 / managerTypeRoleShareSince
MEDICALODGES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2022
MCBRIDE, TRAVISIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 05/01/2022
BUTLER, RICHARDIndividualCORPORATE DIRECTORsince 07/01/2003
COX, GARENIndividualCORPORATE DIRECTORsince 02/26/1998
DOLL, GAYLEIndividualCORPORATE DIRECTORsince 03/10/2005
HINES, SCOTTIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/02/2022
LAGER, SHANNONIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 06/15/2013
MARSHALL, CAROLIndividualCORPORATE DIRECTORsince 07/27/2006
OTT, RONIndividualCORPORATE DIRECTORsince 09/15/2006
CARDENAS, STACIIndividualCORPORATE OFFICERsince 05/28/2013
COOVER, TERESAIndividualCORPORATE OFFICERsince 09/21/2017
LANTZ, KATHLEENIndividualCORPORATE OFFICERsince 10/22/2007
ROHLING MCCORD, CATHERINEIndividualCORPORATE OFFICERsince 06/09/2000
SMITH, PAMELAIndividualCORPORATE OFFICERsince 10/09/2009
WAECHTER HARMON, LORIIndividualCORPORATE OFFICERsince 03/31/2018

CMS files one row per role, so the 18 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$9.7M
Net patient revenuemost recent cost report
-3.8%
Operating marginrevenue minus expenses
$485K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 11%Other / private 89%

This home reported $485K 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

$291per resident / day
operating cost
$8,843per month
≈ monthly operating cost
$280per day
avg. revenue, all payers

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

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175290. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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