Colby Operator, LLC
105 East College Drive, Colby, KS 67701 · For profit - Partnership · 40 certified beds · (785) 462-6721 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2023
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $40,381 in federal fines (most recent 2024-08-12)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (65%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.7% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.9% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.9% | 1.6% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 7.3% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.8% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.5% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.5% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 33.1% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.1% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.8% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.9% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 29.2% | 18.1% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.58 | 1.80 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 3.56 | 2.13 | 1.80 | worse |
‡ 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.
49.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 51% of this home’s weekday level — it runs therapy at close to weekday levels right through 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.0%CMS range 35.3–60.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 5.9–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.5–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 40 beds and averages 35.4 residents a day — about 88% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 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 3.37 hrs/resident/day on weekends vs 4.06 on weekdays — 17% thinner on weekends. RN hours go from 0.47 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 65% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · J2024-08-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 34 residents with three residents reviewed for pressure ulcers. The facility failed to identify and provide appropriate interventions consistent with the standards of care to prevent pressure ulcers from developing and worsening for Resident (R) 1. On 03/11/24, R1 developed two facility-acquired Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) to her bilateral buttocks. On 05/16/24 the wound specialists identified diffuse pressure and redness to the entire intergluteal cleft (a deep groove that separates the buttocks and runs from the third or fourth sacral spine to the anus) area. The facility did not implement further preventative measures to address offloading or positioning until 07/11/2024. The facility further failed to assess R1's pressure wounds weekly to determine the effectiveness of treatments.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-06-11 · tag F0729 — widespreadVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 12 residents, of which five were reviewed for sufficient and competent nurse staffing. Based on the record review and interview, the facility failed to verify one of the five Certified Nurse Aides (CNA) had a current license prior to employing her and allowing her to work the floor providing resident care. Findings included: - Review of the CNA Kansas Department for Aging and Disability Services (KDADS) nurse aide registry confirmation notice revealed CNA P's nurse aide license had expired on [DATE]. Review of the facility's date of hire information revealed CNA P was hired on [DATE]. On [DATE] at 02:37 PM, Consultant Staff GG verified CNA P license was inactive on [DATE], and the verification was conducted today. Consultant Staff GG stated Administrative Staff B was responsible for verifying CNAs' licenses were current before hiring them. Consultant Staff GG verified CNA P was scheduled to work the evening shift today, and she would not be working.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 12 residents, with one reviewed for dignity and respect. Based on observation, record review, and interview, the facility failed to promote dignity for one resident, Resident (R) 3, who was left uncovered in bed with only an incontinence brief on. This placed R3 at risk for impaired dignity. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), diabetes mellitus (DM - when the body cannot use glucose, no enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), benign prostatic hyperpiesia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), and peripheral vascular disease (PVD - slow and progressive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with resident-centered interventions for Activities of Daily Living (ADL) for one resident, resident (R) 25. This placed the resident at risk for unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R25 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R25's Annual Minimum Data Set (MDS), dated [DATE], documented R25 had moderately impaired cognition. R25 required set-up…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 12 residents, with one reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide consistent bathing and grooming for one resident, Resident (R) 25. This placed the resident at risk for complications related to poor hygiene and impaired dignity. Findings included: - The Electronic Medical Record (EMR) for R25 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and major depressive disorder (a major mood disorder that causes persistent feelings of sadness). R25's Annual Minimum Data Set (MDS), dated [DATE], documented R25 had moderately impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold insulin (medication that lowers the level of glucose [a type of sugar] in the blood) when the medication was out of the physician's ordered parameters for one resident, Resident (R) 3. This placed the resident at risk for adverse effects related to medication. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), diabetes mellitus (DM - when the body cannot use glucose, no enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), benign prostatic hyperpiesia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 33 residents who resided in the facility and received meals from the facility kitchen, placing the residents at risk for food borne illness. Findings included: - On 09/26/23 at 11:55 AM observation revealed the ceiling light fixtures above the stove, grill top, steam table, and three-compartment sink all had dead insect in them. The dining room ceiling light cover also contained dead insects. Further observation revealed the front sheath and blades of the fan attached to the wall and venting ducts over the area where clean dishes were stored had brown, fuzzy material hanging from them. Throughout multiple observations of the kitchen and dining room, a large number of flies were also noted landing on the food preparation tables in the kitchen, the dining room tables, and food on the plates which the residents had to wave away during the meal. On 09/26/23 at 02:09 PM Dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-28 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. Based on interview, and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit the information for Licensed Nurses (LN) 24 hour/day staffing as required. This placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2022 Quarter 4 and FY 2023 Quarters 1 through 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on over 75 dates. Review of the faciliyt provided staffign information revealed the facility had a licensed nurse 24 hours a day, seven days a week. On 09/28/23 at 08:30 AM, Administrative Staff B stated she started in October and was given a crash course on the PBJ reporting. She said she has since learned how to input it correctly, and felt that it was the agency nursing staff that had not been input correctly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-28 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
- On 09/26/23 at 07:55 AM, observation revealed R27 in the dining room. His oxygen tubing and cannula laid on the dining room floor. On 09/26/23 at 08:58 AM, observation revealed R27 self propelled his wheelchair into the television area, his oxygen tubing and cannula was wound around the right wheel of his wheelchair. Further observation revealed Administrative Staff B asked Administrative Nurse E to get R27 a new set of tubing sine R27's touched the ground. Administrative Nurse E replaced the old tubing and assisted R27 with the new tubing. Continued observation revealed, the oxygen tank R27 was using was empty and Adminsitrative Nurse E brought R27 a new tank. Administrative Nurse E obtained R27's oxygen saturation (percentage of oxygen in the blood) which was in the 70 percentile (normal is 90-100 %). After Administrative Nurse E had R27 take deep breaths, he was able to get his saturations up into the 90 percentiles. Administrative Nurse E stated it was everyone's responsibility to make sure R27 had a full oxygen tank and to make sure he was wearing the nasal cannula correctly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-28 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. Based on observation and interview, the facility failed to maintain an effective pest control program for the 33 resident's residing in the facility. This placed the resident's at risk for illness and an uncomfortable environment. Findings included: - On 09/25/23 at 11:21 AM, observation revealed during the noon meal, R132 had flies land on her food. On 09/25/23 at 11:30 AM meal, R2 complained about all the flies that landed on his food and onto the table. On 09/25/23 at 12:50 PM, observation in R14's room revealed multiple flies landing on and around the resident as he was transferred by staff. On 09/26/23 at 10:00 AM, R2 stated the flies were terrible in his room. As he spoke, a fly landed on his nose. On 09/26/23 at 12:00 PM, observation revealed R2, in the television area, with a fly swatter in his hand as he tried to kill flies. On 09/27/23 at 02:00 PM, observation revealed several flies landed on R9 while she sat in her recliner. On 09/27/23 at 05:00 PM, observation revealed flies on R9 as she sat in the television area. On 09/27/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-28 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to adequately label and store insulin (hormone that lowers the level of glucose in the blood) for five residents in the facility's medication room. This placed the affected residents at risk for ineffective medication regimens. Findings included: - On 09/25/23 at 01:59 PM, observation of the medication room refrigerator had the follwoing insulin pens which were open, and in use which lacked a date when opened and/or discard date: Residents (R)1's Levemir (long acting insulin) and lispro (short acting insulin) was not labeled with opened or discard dates. R2's Levemir was not labeled with opened or discard date. R14's insulin glargine (long acting) was dated 07/23/23 but not specified if that was an open or discard date. R24's Levemir was dated 09/17/23 but notspecified if that was an open or discard date. R11's basaglar (long acting insulin) was not labeled with opened or discard date. On 09/25/23 at 02:05 PM, Licensed Nurse (LN) G…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2023-09-28 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents, with two reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 14 remained free from neglect when the facility failed to provide the necessary care and service as directed by the resident's plan of care, on more than one occasion, despite being aware of what care the resident required. This placed the resident at risk for congoing neglect and related complications. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following other cerebrovascular accident (CVA-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, muscle weakness, abnormalities of gait and mobility, and lack of coordination. The admission Minimum Data Set (MDS), dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R)16 and R18 for posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed R16 and R18 at risk for unmet care needs. Findings included: - R16's Electronic Medical Record (EMR) recorded diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, mood {affective} disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-28 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to revise Resident (R) 28's plan of care to reflect his current needs and use of a mechanical lift for transfers. This placed the residents at risk for preventable accidents and injury due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R28 documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), unsteadiness on feet, and abnormalities of gait and mobility. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R28 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, personal hygiene, and R28 did not ambulate. The assessment further documented R28 had unsteady balance, upper and lower functional impairment on one side, and had no falls. The Quarterly MDS, dated 07/26/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents. Based on record review, and interview, the facility failed to complete a discharge summary, a reconciliation (summary) of pre and post discharge medications, and post-discharge plan of care for Resident (R) 30, who discharged from the facility. This placed the resident at risk for unmet care needs. Findings included: - The Electronic Medical Record (EMR) documented R30 had diagnoses of fracture of neck of right femur (thigh bone), right artificial hip joint, major depressive disorder (major mood disorder which causes persistent feelings of sadness) , chronic kidney disease, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), fluid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to provide an environment free from preventable accidents and falls for Resident (R)9, R14, and R20. This placed the residents at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R9 documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), repeated falls, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 had a census of 33 residents. The sample included 15 residents, with four reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 27, who required continuous supplemental oxygen, received adequate respiratory care and services. This placed the resident at risk for physical decline. Findings included: - The Electronic Medical Record (EMR) for R27 documented diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and muscle weakness. The Annual Minimum Data Set (MDS), dated [DATE], documented R27 had moderately impaired cognition and required supervision and one person assistance for toileting, personal hygiene, and supervision and set up assistance for all other activities of daily living. The MDS further documented R27 had shortness of breath with exertion, sitting, lying flat, and received oxygen. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 16 and R18 received trauma informed care to eliminate or mitigate triggers that may care re-traumatization which placed the residents at risk for unmet behavioral health care needs and impaired psychosocial well-being. Findings included: - R16's Electronic Medical Record (EMR) recorded diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, mood {affective} disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure residents remained free from significant medication errors when medication was not administered per physician orders for Resident (R) 81. This placed the resident at risk for decreased physical and mental well-being. Findings included: - The Electronic Medical Record (EMR) for R81 documented diagnoses of delusion (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-05-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 27 residents. Based on observation, record review, and interview the facility failed to provide a backflow device (unwanted flow of water in the reverse direction) or a two-inch air gap for the drainage system of the kitchen ice machine, used by the 27 residents who resided in the facility. This placed the affected residents at risk to receive contaminated ice. Findings Included: - On 05/11/22 at 11:26 AM, observation revealed a two-inch plastic drainpipe extended from the back of the ice machine approximately 10 feet and inserted into a floor drain under a cabinet. Continued observation revealed the ice machine drainage system had no backflow device or two-inch air gap at the floor drain. On 05/11/22 at 11:28 AM, Dietary Staff Manager BB verified the ice machine drainage system did not have a backflow device, or two-inch air gap to prevent possible backflow contamination into the ice supply. The facility's Ice Machine, policy, dated August 2011, directed staff to ensure the ice machine had an appropriate drainage system to prevent contamination of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents of which one was reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions for respiratory assessment and care of respiratory equipment for Resident (R) 24, who required oxygen and nebulizer treatments (device which changes liquid medication into a mist easily inhaled into the lungs). This placed R24 at risk for miscommunication related to respiratory cares. Findings included: - R24's Electronic Medical Record (EMR) documented he had diagnoses of shortness of breath and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). R24's Annual Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required total staff assistance with locomotion on the unit, extensive staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents, with one reviewed for urinary catheter. Based on observation, record review, and interview, the facility failed to maintain appropriate handling of urinary catheter tubing to ensure safe positioning and avoid contact with the floor for one sampled resident, Resident (R) 17. This placed the resident at risk for the catheter tube kinking, dislodging, and urinary tract infections (UTIs). Findings included: - The Physician Order Sheet, dated 05/01/22, recorded R17 had diagnoses of dementia (persistent mental disorder marked by memory loss and impair reasoning), traumatic brain injury (an injury that affects normal brain function), end-stage renal disease (condition in which kidneys lose normal function) and urinary retention (condition in which the bladder is unable to empty). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R17 had a Brief Interview for Mental Status (BIMS) score of eleven (moderate cognitive impairment) 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.
- Potential for harm · Dcited before2022-05-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 had a census of 27 residents. The sample included 12 residents with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide appropriate respiratory care and services for Resident (R) 24 who required oxygen and nebulizer treatments. This placed R24 at risk for infection and respiratory complications. Findings included: - R24's Electronic Medical Record (EMR) documented he had diagnoses of shortness of breath and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). R24's Annual Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required total staff assistance with locomotion on the unit, extensive staff assistance with bed mobility, and transfers and received oxygen continuously. R24's Respiratory Care Plan, dated 04/05/22, informed the staff the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 27 residents. The sample included 12 residents and two closed record residents. Based on record review, and interview the facility failed to ensure the availability of physician ordered pain medication for one of 14 sampled residents, Resident (R) 30. This placed R30 at risk for untreated pain. Findings included: - The Physician Order Sheet, dated 02/14/22, recorded R30 had diagnoses of lower end right femur (thigh bone) fracture, right leg non weight bearing status, and chronic pain. R30's Electronic Medical Record (EMR), documented the facility admitted R30 on 02/14/22 and had not completed the resident's admission Minimum Data Set (MDS) or admission care plan. The admission Note, dated 02/14/22, recorded R30 was non weight bearing on her right leg, always wore a hinged knee immobilizer on her right leg and required extensive staff assistance with repositioning and transfers. The admission Note recorded R30 was alert and oriented, able to accurately report her pain, directed staff to provide pain medication as ordered by the physician and monitor the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 21's, R22 and R25's insulin (hormone which allows cells throughout the body to uptake glucose) pens with the date opened, on one of two medication carts. This placed these residents at risk for ineffective medications. Findings included: - On 05/09/22 at 10:50AM, observation of the 200-300 hallway medication cart revealed the following: R21's Humalog (fast acting insulin) kwik pen lacked a date when opened and a date of expiration. R22's Levimer (long acting insulin) flex pen lacked a date when opened and a date of expiration. R25's Levimer flex pen lacked a date when opened and a date of expiration. On 05/09/22 at 11:00AM, Licensed Nurse (LN) H, verified the undated insulin and stated the insulin is to be dated when opened. On 05/12/22 at 11:15AM, Administrative Nurse D, verified the insulin in the medication cart should be dated when opened for use. The facility's Storage of Medications, dated 05/2021, documented…
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.
- No harm found · C2023-09-28 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of 33 residents. The sample included 15 residents. Based on observation and interview, the facility failed to display current daily nursing staffing hours as required. Findings included: -During the survey on 09/25/23 and 09/26/23, observation revealed the nursing hours posted with a date of 09/05/23. On 09/28/23 at 04:00 PM, Consultant Staff HH verified the nursing hours posted were incorrect and she had corrected the posting. Upon request the facility did not provide a staff posting policy. The facility failed to display current daily nursing hours as required.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$40,381 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $40,381 — penalty dated 2024-08-12
- Medicare payment denial — starting 2024-09-10 for 1 days
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 MISSION HEALTH COMMUNITIES — 30 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.8 | -1.8 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 1 of 5 | 2.9 | -1.9 vs chain |
| Quality measures | 1 of 5 | 2.9 | -1.9 vs chain |
The other 29 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KANSAS OPERATOR LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/25/2015 |
| BARRES, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| T AND C CAPITAL ASSETS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| WINDWARD HEALTH PARTNERS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| CRINO, BRYAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| FEUER, SCOTT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| LINDEMAN, STUART | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| PASSERO, JOSEPH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/26/2015 |
| YOAKUM, JAMIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/16/2024 |
| MISSION HEALTH COMMUNITIES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/26/2015 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $246K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175202. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-11, 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 →
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