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Good Samaritan - Ellis

1101 Spruce Street, Ellis, KS 67637 · Non profit - Corporation · 42 certified beds · (785) 726-3101 Medicare & Medicaid certified

Call the home — (785) 726-3101 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Aug 2022Behavioral-health or dementia-care citation — no harm found (F0740)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 20% of its spending goes to commonly-owned related companies

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
814 Jefferson St · (785) 520-5020 · Call to confirm hours
Pharmacy
Peoplesway12.4 mi
3715 Country Ln · (785) 625-8010 · Call to confirm hours
Grocery
1106 Washington St · (785) 726-4513 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1201 Washington St · (785) 726-3372

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 3 of 5
Long-stay residentspeople who live here 2 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 4 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 rating4★
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 increased20.0%17.9%15.4%worse
Long-stay residents who lose too much weight6.5%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder2.4%1.6%0.9%worse
Long-stay residents with a urinary tract infection1.5%2.9%2.0%better
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 injury4.3%4.3%3.3%worse
Long-stay residents whose ability to walk worsened16.0%16.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication24.4%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine97.4%95.5%95.3%typical
Long-stay residents with pressure ulcers3.1%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control29.2%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.7%18.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents rehospitalized after admission17.7%22.4%22.6%better
Short-stay residents with an outpatient ER visit8.5%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.401.801.67worse
Long-stay outpatient ER visits per 1,000 resident days2.222.131.80worse

* 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.

10.6%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.11U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy

Met the expected recovery: 50.0% 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 20 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 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.3–17.710.7%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 discharge50.0%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 discharge25.0%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 discharge40.0%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 identified100.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened4.0%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 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

0.73
RN hours/ resident / day
0.54
LPN hours/ resident / day
2.46
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.43
RN hoursweekends
28.9%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 42 beds and averages 35.3 residents a day — about 84% occupied, or roughly 7 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 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 3.15 hrs/resident/day on weekends vs 3.97 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.85 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-12-11)
6
at the previous standard inspection (2024-03-11)

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2026-01-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 37 residents, with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to prevent a hot liquid burn to Resident (R) 1. The facility failed to evaluate the temperature of the liquid from the hot water/coffee machine, relying on a temperature regulator that had failed, and allowed the hot water dispensed from the machine to be too hot.Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), gastroparesis (a chronic digestive disorder where the stomach muscles weaken, slowing or stopping food from moving into the small intestine), epilepsy (brain disorder characterized by repeated seizures), and convulsions (involuntary series of contractions of a group of muscles).The Significant Change Minimum Data Set (MDS) dated 11/13/25 documented R1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R1 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 · Past Non-Compliance
  • Potential for harm · Dcited before2025-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment when the facility failed to assess Resident (R) 26 for safe use of an electric recliner. Findings included:- R26's Electronic Medical Record (EMR) recorded dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), wedge compression fracture thoracic spine levels 11-12, and muscle weakness. R26's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R26 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS recorded R26 was independent with activities of daily living and had one fall, no injury. R26's Fall Care Area Assessment (CAA) dated 05/05/25 documented R26 was at risk for falls due to use of antidepressant (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility's Consultant Pharmacist failed to identify staff were not obtaining Resident (R) 7's blood pressure before the administration of losartan, as ordered. Findings Included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of hypertension (elevated blood pressure), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat). The Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R7 had intact cognition. The MDS further documented R7 received diuretic (a medication to promote the formation and excretion of urine) medication. The Quarterly MDS dated 10/23/25 documented R7 had intact cognition. The MDS documented R7 received diuretic medication. R7's 10/17/25 Care Plan included the following interventions: 06/15/16 - Directed staff to administer…

    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 · D2025-12-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for one resident. The facility failed to obtain weekly blood pressures as ordered for Resident (R) 7, who received hypertension (high blood pressure) medication.Findings included:- The Electronic Medical Record (EMR) for R7 documented diagnoses of hypertension, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat).The Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R7 had intact cognition. R7 was dependent upon staff for toileting hygiene, dressing, and transfers. The MDS documented R7 required set-up staff assistance for oral hygiene, showers, and personal hygiene. The MDS further documented R7 received diuretic (a medication to promote 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-11 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to employ a full-time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 35 residents of the facility at risk for inadequate nutrition or food-borne illness. Findings included: - On 03/05/24 at 810 AM, observation revealed Dietary Staff (DS) DD and EE served breakfast to the residents in the dining room. On 03/05/24 at 08:35 AM, Administrative Staff A verified the Dietary Manager was not certified. The facility's Food and Nutrition Services policy, dated 01/02/24, stated the person in charge of the food and nutrition department is responsible for department operation and must meet one of the following criteria: A Certified Dietary Manager (CDM) by the Association of Foodservice and Nutrition Professionals. A Certified Food Service Manager (CFM) by the International Foodservice Executives Association. Similar national certification food service…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-11 · tag F0851 — widespread
    Electronically 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 35 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on the following days: 01/14/23, 02/05/23, 02/26/23, and 03/19/23. The PBJ report for FY 2023 Quarter 3 indicated no licensed nurse coverage on 04/08/23, 04/30/23, 05/20/23, 05/21/23 and 06/11/23. A review of the facility's licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 03/06/24 at 11:30 AM, Administrative Nurse D verified the facility failed to submit accurate nursing hour data for the PBJ. She verified the nurse clock-in hours for all the days. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-11 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility had a census of 35 residents. Based on record review and interview, the facility failed to ensure one of the five Certified Nurse Aides (CNA) employed at the facility for at least one year completed the minimum 12 hours of in-service training per year and lacked a system for accurately tracking CNA education. Findings included: - A review of the facility's CNA Training Records for CNA staff who had been employed at the facility for over one year revealed a lack of 12-hour in-service training for CNA M, hired 02/15/22. The records recorded that CNA M completed 4.5 hours. On 03/06/24 at 02:20 PM, Administrative Nurse D stated the facility had not monitored the completion of CNA in-service hours and verified that one of the five CNAs lacked the 12 hours of yearly in-service training. Upon request, the facility did not provide a policy for nurse aide in-service continuing education. The facility failed to ensure one of the five CNA staff reviewed completed the minimum 12 hours of in-service training per year and lacked a system for accurately tracking CNA education.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-11 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff administered an injection to Resident (R) 2 beside the front entry to the facility and in view of other residents and when residents were served meals in Styrofoam bowls instead of regular dinnerware. This placed the residents of the facility at risk for impaired dignity. Findings included: - On 03/05/24 observation during the lunch meal service revealed staff provided Styrofoam bowls for baked beans and desserts. On 03/07/24 at 12:52 PM, observation revealed Licensed Nurse (LN) G obtained a finger stick blood sugar from R2 and then administered insulin (a hormone that lowers the level of glucose in the blood) in R2's abdomen, by the front entry with one male resident nearby and a resident watching from the dining room. On 03/05/24 at 12:17 PM, DS BB stated the facility used the Styrofoam bowls because the beans would run into the other foods 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to ensure the residents' dinnerware was not broken or chipped. This placed the 35 residents at risk for unsafe food service. Findings included: - On 03/07/24 at 12:00 PM, Dietary Staff (DS) CC served meals in the facility kitchen. Observation revealed a stack of plates with four chipped plates which DS CC used during the meal service. On 03/07/24 at 01:23 PM, Consultant GG verified the chipped plates could be a safety or sanitation concern and said chipped dinnerware should not be used. The facility's Dining Service Standards policy, dated 07/21/23, directed staff to not use stained, chipped, or worn dishes or glassware. The facility failed to ensure the residents' dinnerware was not broken or chipped. This placed the 35 residents at risk for unsafe food service.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 14 residents with three reviewed for weight loss. Based on observation, interview, and record review the facility failed to identify and implement interventions to prevent weight loss for Residents (R) 14. This deficient practice placed the resident at risk for further weight loss or health issues. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), epilepsy (brain disorder characterized by repeated seizures), anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), gastroesophageal reflux (GERD-backflow of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-08-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 31 residents who resided in the facility and received their food from the facility kitchen when the facility failed to ensure dietary staff followed hand hygiene and failed to ensure clean and sanitary food prep areas. This placed the 31 residents at risk for foodborne illness. Findings included: - On 8/24/22 at 11:30 AM observation in the kitchen revealed the following: During serving of the noon meal, Dietary Staff (DS) BB applied gloves, touched her face, steam table, and undercounter fridge door handle. Then, with the same contaminated gloves, took two grilled cheese sandwiches from a plastic bag, and placed them in a frying pan. The mopboard around the kitchen floor had numerous brown stains of various sizes The kitchen ceiling had eight ceiling tiles with numerous different sized brown stains. Three ceiling fluorescent light…

    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 13 citations
  • Potential for harm · E2022-08-29 · tag F0572 — pattern
    Give residents a notice of rights, rules, services and charges.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 31 residents. The sample included five residents. Based on observation, record review, and interview the facility failed to provide ongoing communication to the resident council group about their rights and location of State Long Term Care Ombudsman (LTCO-an official appointed to investigate individual's complaints against maladministration), State Survey Agency (a group which assess whether nursing homes are operating with a quality of care that is in line with standards, applicable laws, and industry regulations) information and the location of the last survey report. This placed the residents at risk for impaired dignity due to decreased autonomy. Findings included: - The Resident Council Minutes, from 08/03/21 to 08/04/22 documented one resident right was reviewed with resident council minutes. The minutes lacked documentation regarding LTCO and State Survey Agency contact information or the last state survey location. On 08/25/22 at 10:00 AM, Resident (R) 4, R7, R8, R11, and R28 attended the resident council meeting with the surveyor and all stated…

    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 before2022-08-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to treat Resident (R) 16 with dignity when staff applied Voltaren gel (a topical medication used to treat arthritis pain) on her shoulders, twice, at the dining room with two other residents present. This placed the resident at risk for an undignified dining experience. Findings included: - R16's Electronic Medical Record (EMR) documented she had diagnoses anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), panic disorder (sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause) and chronic pain and stiffness of joints. R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had a Brief Interview of Mental Status (BIMS) score of seven, which indicated severe impaired cognition. The MDS documented R16 required 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-29 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 14 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to notify Resident (R)11's physician after R11 made the statement she wished she was dead. This placed the resident at risk for further decline of her emotional well-being and delayed mental healthcare treatment. Findings Included: - The Electronic Medical Record (EMR) for R11 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness, and severe stress reaction (occurs when a person experiences certain symptom after a particularly stressful event) The admission Minimum Data Set (MDS), dated [DATE], documented R11 had intact cognition and was independent with all activities of daily living (ADLs). The MDS further documented R11 had thoughts she would…

    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 · D2022-08-29 · 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 had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to immediately respond and investigate a report of alleged inappropriate interaction between a male resident, (R)10 and R11. This placed the residents at risk emotional distress. Findings included: - The Electronic Medical Record (EMR) for R11 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness, and severe stress reaction (occurs when a person experiences certain symptom after a particularly stressful event) The admission Minimum Data Set (MDS), dated [DATE], documented R11 had intact cognition and was independent with all activities of daily living (ADLs). The MDS further documented R11 had thoughts she would be better off dead or hurting herself never or one day, felt…

    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 · D2022-08-29 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 14 residents with one reviewed for hospitalization. Based on observation, record review, and interview the facility failed to provide Resident (R)14 or her representative in writing a notice of transfer to the hospital, which included the reason for transfer, the date, and where R14 was transferred. The facility failed to send a copy of R14's notice for transfer to the hospital to the State Long Term Care Ombudsman. Findings included: - R14's Electronic Medical Record (EMR) documented the resident had diagnoses of iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells) and gastrointestinal hemorrhage (bleeding into the stomach and/or digestive tract) R14's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of nine, which indicated moderately impaired cognition. The MDS documented R14 required extensive staff assistance with bed mobility, transfers,…

    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 · D2022-08-29 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide Resident (R)14 or her representative with written information regarding the facility bed hold policy, when R14 was transferred to the hospital. This placed R14 at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R14's Electronic Medical Record (EMR) documented the resident had diagnoses of iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells) and gastrointestinal hemorrhage (bleeding into the stomach and/or digestive tract) R14's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of nine, which indicated moderately impaired cognition. The MDS documented R14 required extensive staff assistance with bed mobility, transfers, locomotion on and off unit, dressing and personal hygiene, limited 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-29 · 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 had a census of 31 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to develop a discharge care plan for Resident (R) 33, to reflect current needs, goals, treatment and discharge preferences. This placed the resident at risk for miscommunication or interruptions in the continuum of care. Findings included: - The Electronic Medical Record (EMR) for R33 documented diagnoses of femur fracture (broken leg), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and pain (physical suffering or discomfort caused by illness or injury). The admission Minimum Data Set (MDS), dated [DATE], documented R33 had intact cognition and required limited assistance for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. The MDS further documented R33 had lower impairment on one side and expected to be discharged to the community. The EMR lacked 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-29 · tag F0657 — failed to keep the care plan current — isolated
    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 had a census of 31 residents. The sample included 14 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to place interventions on the care plan to prevent falls for Resident (R) 24. This deficient practice placed the resident at risk for further falls due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R24 documented diagnoses of encephalopathy (a disorder of the brain that can be caused by disease, injury, drugs, or chemicals), benign neoplasm of cerebral meninges (brain tumor), epilepsy (a neurological disease marked by sudden recurrent episodes of sensory disturbances and loss of consciousness), and mood disorder (the emotional state or mood is distorted or inconsistent with the circumstances and interferes with the ability to function). R24's admission Minimum Data Set (MDS), dated [DATE], documented R24 had intact cognition and required limited assistance of one staff for transfers,…

    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 · Dcited before2022-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 14 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement interventions for accidents for one sampled resident, Resident (R) 24, who had multiple falls and failed to use two staff when transferring R27 with a full mechanical lift (used to assist with transfers and movement of individuals who require support for mobility). This placed the residents at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R24 documented diagnoses of encephalopathy (a disorder of the brain that can be caused by disease, injury, drugs, or chemicals), benign neoplasm of cerebral meninges (brain tumor), epilepsy (a neurological disease marked by sudden recurrent episodes of sensory disturbances and loss of consciousness), and mood disorder (the emotional state or mood is distorted or inconsistent with the circumstances and interferes with the ability to function). R24's…

    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 before2022-08-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 14 residents which one was reviewed for hydration. Based on observation, record review, and interview the facility nursing staff failed to monitor Resident (R) 15's, who was on a physician ordered fluid restriction, fluid intake. This placed R15 at risk for fluid overload. Findings included: - R15's Electronic Medical Record (EMR) documented the resident had diagnoses of heart failure, hyponatremia (low sodium level) and hypomagnesia (low level of magnesium, an electrolyte, in your blood). R15's Quarterly Minimum Data Set (MDS), dated [DATE], documented R15 had a Brief Interview of Mental Status score of four, which indicated severe cognitive impairment. The MDS documented the resident required limited staff assistance with eating, toileting, and personal hygiene, supervision with walk in room and corridor, bed mobility, and locomotion on and off unit, and was independent with transfers. The MDS documented the resident had no weight loss or gain. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-29 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 14 residents, with four reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one sampled resident, Resident (R) 11, who stated she wished she was dead. This placed the resident at risk for further decline of her emotional and mental-wellbeing and risk for self-harm. Findings included: - The Electronic Medical Record (EMR) for R11 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness, and severe stress reaction (occurs when a person experiences certain symptom after a particularly stressful event) The admission Minimum Data Set (MDS), dated [DATE], documented R11 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 · D2022-08-29 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sampled resident, Resident (R) 11, who had made a statement that she wished that she was dead and had an alleged inappropriate interaction with a male resident ,R10. This placed the resident at risk for further decline of her emotional and mental-wellbeing. Findings included: - The Electronic Medical Record (EMR) for R11 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness, and severe stress reaction (occurs when a person experiences certain symptom after a particularly stressful event) The admission Minimum Data Set (MDS),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-29 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 17 medication administration was free from significant errors when staff crushed one extended release medication. This placed R17 at risk for side effects related to the medication being improperly released and decreased therapeutic effect. Findings included: - On 08/24/22 at 08:18 AM, observation revealed Licensed Nurse (LN) I, during medication administration, crushed R17's metoprolol (medication used to treat chest pain, heart failure, and high blood pressure) extended release (ER),12.5 milligram (MG) tablet. Observation revealed LN I placed the crushed metoprolol with the other medications she had crushed and placed in applesauce and administered the medications to R17. On 08/24/22 at 08:44 AM, LN I verified she crushed the above medication and stated she was unaware it could not be crushed. LN I stated usually if a medication cannot be crushed, there was a physician order stating not to crush the medication…

    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

“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

No federal fines in the current CMS record.

Part of a chain

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

RatingThis homeChain avg
Overall 5 of 53.0+2.0 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 5 of 54.0+1.0 vs chain
Quality measures 3 of 52.8+0.2 vs chain
The other 91 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Edgebrook Care CenterEdgerton, MN 1 of 5Good Samaritan - IndianolaIndianola, IA 1 of 5Good Samaritan - Red OakRed Oak, IA 1 of 5Good Samaritan Society - AtkinsonAtkinson, NE 1 of 5Good Samaritan Society - BlackduckBlackduck, MN 1 of 5Good Samaritan Society - Grand Island VillageGrand Island, NE 1 of 5Good Samaritan Society - LakotaLakota, ND 1 of 5Good Samaritan Society - Mary Jane BrownLuverne, MN 1 of 5Good Samaritan Society - St Luke's VillageKearney, NE 1 of 5Good Samaritan Society - WindomWindom, MN 1 of 5Good Samaritan Society De SmetDe Smet, SD 1 of 5Good Samaritan Society MillerMiller, SD 1 of 5Salem Lutheran HomeElk Horn, IA 1 of 5Souris Valley Care CenterVelva, ND 1 of 5St Vincent's - A Prospera CommunityBismarck, ND 1 of 5Sunset Drive - a Prospera CommunityMandan, ND 2 of 5Good Samaritan - AtwoodAtwood, KS 2 of 5Good Samaritan - Decatur CountyOberlin, KS 2 of 5Good Samaritan - EsthervilleEstherville, IA 2 of 5Good Samaritan - MansonManson, IA 2 of 5Good Samaritan - OttumwaOttumwa, IA 2 of 5Good Samaritan - WaukonWaukon, IA 2 of 5Good Samaritan Society - BottineauBottineau, ND 2 of 5Good Samaritan Society - Hastings VillageHastings, NE 2 of 5Good Samaritan Society - OakesOakes, ND 2 of 5Good Samaritan Society - Park RiverPark River, ND 2 of 5Good Samaritan Society - Specialty Care CommunityRobbinsdale, MN 2 of 5Good Samaritan Society - St John'sKearney, NE 2 of 5Good Samaritan Society - St Martin VillageRapid City, SD 2 of 5Good Samaritan Society - SuperiorSuperior, NE 2 of 5Good Samaritan Society - Waconia And Westview AcreWaconia, MN 2 of 5Good Samaritan Society CantonCanton, SD 2 of 5Good Samaritan Society Luther ManorSioux Falls, SD 2 of 5Good Samaritan Society New UnderwoodNew Underwood, SD 2 of 5Good Samaritan Society Sioux Falls CenterSioux Falls, SD 2 of 5Good Samaritan Society Sioux Falls VillageSioux Falls, SD 2 of 5Good Samaritan-LiberalLiberal, KS 2 of 5The Good Samaritan Society-Kissimmee VillageKissimmee, FL 3 of 5Good Samaritan - AlgonaAlgona, IA 3 of 5Good Samaritan - DavenportDavenport, IA

Showing 40 of 91; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
SANFORDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/01/2019
THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETYOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/01/2019
BROWN, GEORGEIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2025
DYKHOUSE, DANAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
ENGBRECHT, WESLEYIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
GASSEN, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 05/30/2024
GULSVIG, NEILIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
HERSETH SANDLIN, STEPHANIEIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
LUNDEEN, MARKIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
MCCAUSLAND, MAUREENIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2025
MOLBERT, LAURISIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
NORTH, ANDREWIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
SCHIEFFER, KEVINIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2025
SHULKIN, DAVIDIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
TEIKEN, BRENTIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
VENTLING-HERRMANN, MARNIEIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
WENZEL, THOMASIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2025
FLUIT, JOELIndividualCORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 03/09/2026
MIDDLETON, AIMEEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/27/2022
OLSON, NICHOLASIndividualCORPORATE OFFICER; ADP OF THE SNFsince 04/08/2024
SCHEMA, NATHANIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2022
DE ANDRADE, PAULOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
LEUENBERGER, SHARONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/19/2024
MORRISON, TONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
SANDGREN, DEEANDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2023
DTN STAFFING INCOrganizationADP OF THE SNFsince 08/02/2024
FOCUSONE SOLUTIONSOrganizationADP OF THE SNFsince 03/04/2024
GRAPE TREE MEDICAL STAFFING LLCOrganizationADP OF THE SNFsince 04/13/2018
OMNICARE LLCOrganizationADP OF THE SNFsince 01/01/2019

CMS files one row per role, so the 56 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$3.5M
Net patient revenuemost recent cost report
-1.8%
Operating marginrevenue minus expenses
$704K
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 4%Other / private 37%

This home reported $704K paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$246per resident / day
operating cost
$7,471per month
≈ monthly operating cost
$241per 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 175328. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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 →

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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