Emporia Presbyterian Manor
2300 Industrial Road, Emporia, KS 66801 · Non profit - Corporation · 60 certified beds · (620) 343-2613 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)
- a high payroll-based staffing rating (4/5)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- 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 (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $30,244 in federal fines (most recent 2024-05-15)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 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 | 21.5% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.7% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 4.1% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.1% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.6% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.7% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.7% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 4.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 29.1% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 65.0% | 73.8% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.65 | 1.80 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 3.72 | 2.13 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.5% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.5% 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 23 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 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.5%CMS range 28.9–54.1 | 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 | 10.9%CMS range 6.7–16.5 | 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 | 56.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 34.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 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 | 0.0% | 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 | 10.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 51.6 residents a day — about 86% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.12 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 3.96 hrs/resident/day on weekends vs 4.61 on weekdays — 14% thinner on weekends. RN hours go from 0.96 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents, with one resident reviewed for elopement. The facility failed to ensure staff provided appropriate supervision for cognitively impaired Resident (R1), who resided in a locked memory care unit, when staff accompanied the resident to the Chapel in the Independent Living Facility area for podiatry services, then left the resident with the contract service staff. On 08/24/23 at 10:10 AM, R1 exited the chapel, ambulated with his walker approximately 100 feet to the unlocked facility exit door, and exited the facility door. R1 then turned right, walked around the front of the building, approximately 400 feet, and sat on the bench under the canopy outside of the entrance door to the facility. On 08/24/23 at 10:25 AM, Certified Nurse Aide (CNA) M observed R1 seated on the front bench, outside of the facility, and notified Administrative Nurse A by phone. CNA M reported she sat outside with R1 for approximately five minutes after notifying Administrative Nurse A, but then…
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.
- Immediate jeopardy · J2022-11-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to identify and assess risk factors for ileus (obstruction of the intestines, caused by immobility of the bowel) and bowel obstruction (a blockage of the flow of bowel stream) and failed to provide the necessary care and services to respond to symptoms related to an ileus for Resident (R) 37, who admitted to the facility with a diagnosis of ileus on 10/21/21. R37's care plan lacked direction to staff regarding bowel management. On 08/21/22 R37 reported abdominal pain, nausea, and vomiting. She had a liquid stool on that day. On 08/22/22 R37 reported abdominal pain and the staff failed to assess bowel sounds or consider the symptoms relative to the resident's history of ileus. R37 then had no recorded bowel movement from 08/22/22 through 08/25/22 and the staff did not perform a bowel assessment in response to the lack of bowel movements. The record documented R37 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-03-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 51 residents with one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the spread of food borne illness to the residents of the facility. This placed the residents at risk for food-borne illness.Findings included:- Initial tour of the kitchen on 03/02/2026 at 07:29 AM with Dietary Manager BB, revealed the following areas of concern:An uncovered plastic tub containing metal spoons sitting on counter in dining area at entrance to kitchen.Five blocks of butter in a metal container uncovered on the counter.The refrigerator contained bowls of spaghetti, milk, cottage cheese, and yogurt on a tray covered with plastic wrap r with no open or use by date.The freezer contained 5 cups of pudding and a piece of pie, two packages of shredded cheese, 2 sheet pans of Jello and 7 sausage links that were not labeled and dated.The spice rack on the wall behind the stove had an open package of brown sugar that did not have an opened-on date. A container labeled…
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 · D2026-03-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 51. The sample included 14 residents. Based on record review, interview, and observation revealed the facility failed to provide care for Resident (R)11 and R19 in a manner that protected and promoted their dignity. Findings included:- On 03/02/26 at 12:10 PM, observation revealed R11 sat in a chair at the dining room table. Licensed Nurse (LN) G obtained R11's blood sugar reading using a glucometer (an instrument used to calculate blood glucose) from R11's right fourth finger. Continued observation revealed six residents were seated at the dining room awaiting lunch to be served, while other residents were seated in adjacent tables in the dining room, including one visitor and staff. On 03/02/26 at 12:20 PM, R11 got up from the dining room table, walked to her room, and laid down. Observation revealed she had see-through, thin material pink pants and her brief was visible through the pants. On 03/03/26 at 07:45 AM, R11 walked to the dining room table and sat down for breakfast.…
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 · D2026-03-04 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 identified a census of 51 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure reasonable accommodation of needs when staff failed to ensure Resident (R)8's call light was within his reach.Findings included:- R8's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), unsteadiness on feet, muscle weakness, and repeated falls.The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R8 was dependent on staff for toileting and needed supervision or touching assistance from staff with eating.The Falls Care Area Assessment (CAA) dated 01/22/26 documented R8 was at risk for falls related to a history of falls, impaired mobility, weakness, dementia, 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 · D2026-03-04 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 51 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to keep Resident (R) 58s protected health information (PHI) private on a medication cart that sat against the wall in A hall.Findings included: - On 03/03/26 at 08:29 AM, an observation revealed a medication cart parked against the wall in the A hall with a laptop computer sitting on the top. Certified Medication Aide (CMA) R walked away from the medication cart and into a resident's room. CMA R left the computer screen unlocked and opened and R58's PHI was on the screen, visible to all who passed by the medication cart. The information visualized included R58's medications, date of birth , allergy information, and code status. On 03/03/26 at 08:37 AM, CMA R stated she had stepped away from the cart to help a resident. She stated the policy was to ensure the CMA locked the medication cart and pushed the hide button. On 03/04/26 at 08:17 AM, Licensed Nurse (LN) I stated medication carts should be locked and the screen on the laptop should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 51 residents; the sample included 14 residents, with 9 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide follow-up fall assessments for Resident (R) 4 and failed to assess for R7's ability to safely use an electric recliner until after a fall occurred.Findings included:- R7's Electronic Medical Record (EMR) recorded diagnoses of, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), restless leg syndrome (RLS - neurological disorder causing painful urge to move the legs, accompanied by creeping, crawling, or tingling,) and peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet. R7's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. R7 required staff supervision with bed…
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 · D2026-03-04 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 51 residents. The sample included 14 residents, including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the consulting pharmacy failed to identify blood sugars out of range for Resident (R) 3.Findings included:- R3's Electronic Medical Records (EMR) documented diagnoses, which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R3's 05/06/2025 admission Minimum Data Set (MDS) documented R3 had a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. The MDS noted R3 had a diagnosis of diabetes and received an insulin injection every day in the look back period of seven days. The Nutrition Care Area Assessment (CAA) documented R3 was at risk for impaired nutrition related to a stroke, morbid obesity, and diabetes. R3's Care Plan dated 05/06/25 documented that R3 takes insulin and oral diabetes medications and directed staff to monitor and document side effects and effectiveness.…
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 · D2026-03-04 · 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
The facility identified a census of 51 residents. The sample included 14 residents, including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to follow orders for notification of the provider for blood sugars out of range for Resident (R) 3.Findings included:- R3's Electronic Medical Records (EMR), documented diagnoses which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R3's 05/06/2025 admission Minimum Data Set (MDS) documented R3 had a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. The MDS noted R3 had a diagnosis of diabetes and received an insulin injection every day in the look back period of seven days. The Nutrition Care Area Assessment (CAA) documented R3 was at risk for impaired nutrition related to a stroke, morbid obesity and diabetes.R3's Care Plan dated 05/06/25 documented that R3 takes insulin and oral diabetes medications and directed staff to monitor and document side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-04 · tag 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 identified a census of 51 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 8 remained free of significant medication errors when staff failed to administer his potassium (a medication for hypokalemia (low level blood potassium in the blood) ordered by physicians.Findings included:- R8's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of fluid overload, hypokalemia (low potassium), hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), unsteadiness on feet, muscle weakness, and repeated falls.The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS documented R8 received a diuretic (a medication to promote the formation and excretion of urine).R8's Dehydration/Fluid Maintenance Care Area Assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 51 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to ensure staff labeled Resident (R)11's insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened. Findings included:- On 03/02/26 at 07:15 AM, observation of the Medication cart located in the nurse's room revealed R11's Lantus (long-acting insulin) flex pen was not labeled with an opened date or an expiration date. R11's second Lantus insulin flex pen had an illegible date written on the pen as it had smeared and was not legible. On 03/02/26 at 07:20 AM, License Nurse G verified the nurses should label and date the insulin flex pens with the date opened. On 03/04/26 at 10:20 AM, Administrative Nurse D verified the nurse should label and date the insulin flex pens with the date opened. Medlineplus.gov directs open, unrefrigerated insulin pen can be used within 28 days; after that time, they must be discarded. The facility's Medication Storage policy, dated 02/03/25, documented medications and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each 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 51 residents. The sample included 14 residents with one reviewed for dental care. Based on observation, record review, and interview, the facility failed to provide timely dental care for one sampled resident, Resident (R) 6.Findings included:- R6's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R6 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment revealed R6 required staff assistance for personal hygiene, oral hygiene, toilet hygiene and had no oral or dental issues.The Care Area Assessment (CAA), dated 04/28/25, for activities of daily living (ADLs) failed to identify or document any sign/symptoms of dental problems or pain due to the broken, decayed, and missing teeth.The Activities of Daily Living (ADL) Care Plan, dated 01/12/26, recorded R6 required limited to extensive staff ADLs such as grooming, dressing, toileting and dressing. The Care Plan documented R6 had his own teeth, and they were in poor condition,…
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 20 citations
- Potential for harm · D2026-03-04 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 51 residents. The sample included 14 residents with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer and administer or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination for Resident (R)3Findings included:- Review of R3's clinical record revealed the PCV13 was administered on 10/30/15, and the PSV23 was administered on 11/12/04. R3's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician documented contraindication.On 03/04/26 at 08:04 AM, Administrative Nurse D stated the nurse who admitted the resident was responsible for ensuring the resident or family signed a consent or declination for immunizations. Administrative Nurse D stated the signed consent or declination form was uploaded in the resident's chart and Administrative Nurse D was notified if the resident was to receive any immunizations. Administrative Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 reported a census of 46 residents with six residents selected for review and four residents sampled for notification of change. Based on record review and interview, the facility failed to notify the physician timely regarding lack of monthly catheter changes and failed to assess, document, and notify the physician with a change in condition when staff alerted the Licensed Nurse of swelling and redness to R2's penis and scrotum on 08/14/24 at 09:00 PM. On 08/15/24 at 03:52 PM, over 18 hours later, R2 required emergency medical transport for further evaluation and treatment. Findings included: - The Diagnosis tab for Resident (R) 2 included diagnoses of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting his right dominant side, aphasia (condition with disordered or absent language function), neuromuscular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 46 residents with five residents selected for review, including three residents sampled for accidents. Based on record review and interview, the facility failed to investigate a fall on 07/16/24, conduct a complete assessment, and implement a new intervention following the fall for Resident (R)1, that had previous falls in the facility. On 07/17/24, R1 had an additional fall, which the facility failed to complete an assessment and implement a new intervention following the fall. Additionally, the facility failed to notify the responsible party and the physician following falls on 07/16/24 and 07/17/24. Findings included: - The Diagnosis tab lacked diagnosis for R1. The Minimum Data Set (MDS) tab in the electronic medical record revealed R1 entered the facility on 07/12/24 and discharged on 07/17/24. The admission MDS was not due during R1's stay. The Fax sheet dated 07/12/24, from the physician office included diagnoses for medication use, which included mixed incontinence and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-04-15 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 48 residents. The sample included 13 residents. Based on record review and interview, the facility failed to ensure the required members, including the infection preventionist, attended the Quality Assessment and Assurance (QAA) Committee meetings at least quarterly. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 04/12/23, 07/19/23, 10/18/23, 01/24/24, the facility's Quarterly Quality Assurance Performance Improvement (QAPI) Meeting Attendance Sheets lacked evidence the designated infection preventionist attended the meetings. On 04/15/24 at 12:30 PM, Administrative Nurse D verified the lack of a designated infection preventionist signature on the quarterly meeting sign-in sheets and stated the facility had not employed an infection preventionist at the times of the quarterly meetings. The facility's Quality Assurance Process Improvement Plan (QAPI), revised 01/15/24 documented that the goal of the QAPI was to promote autonomy while maintaining safety and quality of care. The steering…
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 before2024-04-15 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 48 residents. The facility had three medication carts. Based on observation, record review, and interview, the facility failed to ensure reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently and per industry standards. This placed residents at risk of medication misappropriation. Findings included: - On 04/11/24 at 07:50 AM a review of the April 2024 Eight Hour Verification Controlled Substance Count sheet on the locked memory care unit revealed a missing signature either for the on-coming nurse signature or the off-going nurse signature on 13 of 62 opportunities. On 04/15/24 at 10:45 AM a review of the April 2024 Eight Hour Verification Controlled Substance Count sheet on the nurse's cart revealed a missing signature either for the on-coming nurse signature or the off-going nurse signature on four of 84 opportunities. On 04/15/24 at 10:50 AM a review of the April 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-15 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 48 residents, with three reviewed for the Center for Medicare and Medicaid Services (CMS) beneficiary liability notices. Based on record review and interview, the facility failed to provide a CMS Form 10055 which included the estimated costs for Resident (R) 32 and R41. This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare Advance Beneficiary Notice (ABN) Form 10055 informed the beneficiaries that Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services but lacked documentation regarding which option the residents choose. A review of the ABN Form 10055…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 48 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide a clean, comfortable, and homelike environment in Resident (R) 35's room. This placed the resident at risk for impaired comfort and dignity. Findings included: - On 04/09/24 at 08:10 AM, observation revealed R35 rested in bed with his eyes closed. There was an overwhelming urine odor in the room. R35's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) was not visible. On 04/09/24 at 10:00 AM, R35's room door was open, and a strong urine odor was noted in the hall in front of R35's door to his room. Further observation revealed an approximately 12-inch (in) x 12-inch area of a yellowish wet spot visible on his sheet. R35 was not in his room. On 04/10/24 at 08:10 AM, observation revealed R35's door was closed, but an overwhelming urine odor was still evident by the entrance to his room. On 04/10/24 at 10:00 AM, observation revealed two maintenance staff cleaned R35's carpet and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-11-22 · tag F0574 — widespreadThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review and interview, the facility lacked posting of the Ombudsman and State Hotline contact numbers which placed the residents at risk of unmet care concerns and impaired ability to contact to the state agencies. Findings included: - On 11/21/22 at 03:15 PM Social Service Designee (SSD) X reported the Ombudsman and state reporting information was posted on C Hall, which was under construction and not accessible to residents. On 11/21/22 at 03:21 PM Administrative Staff A verified the Ombudsman and state reporting information was not posted in a visable location due to construction since September 2022. On 11/22/22 at 09:12 AM Administrative Nurse D stated the Ombudsman and state reporting information should be posted where residents could see them. Upon request the facility failed to provide a policy which regarded the Ombudsman and state reporting information. The facility failed to provide the residents information which included contact information for the Ombudsman and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-11-22 · tag F0801 — widespreadEmploy 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 — the official record, unedited, may be distressing
The facility has a census of 36 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to employ a full time certified dietary manager for the 36 residents who reside in the facility and receive their meals from one of one kitchen, placing the residents at risk for inadequate nutrition Findings included: - On 11/17/22 at 08:31 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. Dietary Staff BB stated he/she had no certification as a dietary manager and was currently enrolled in the dietary manager classes. Upon request, the facility did not provide a policy regarding Certified Dietary management requirements. The facility failed to employ a full time Certified Dietary Manager, for the 36 residents residing in the facility who received meals from one of one kitchen, placing the residents at risk for inadequate nutrition.
- Potential for harm · E2022-11-22 · tag F0572 — patternGive 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 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to educate residents routinely of their Resident Rights which placed the resident at risk for inability to exercise their rights. Findings included: -On 11/22/22 record review of the Resident Council Meeting Minutes revealed a lack of evidence staff reviewed the Resident Rights. On 11/22/22 at 01:30 PM Resident Council member, Resident (R) 26, reported the staff had not reviewed the Resident Rights during the Resident Council meetings. On 11/22/22 at 03:15 PM Social Service Designee (SSD) X stated she had not reviewed the Resident Rights during the Resident Council meetings. SSD X stated the Resident Rights were given on admission, mailed out for the care plan meetings, and staff inquired after care plan meetings if residents had concerns related to their rights. Upon request the facility failed to provide a policy related to Resident Rights. The facility failed to review/educate residents routinely of Resident Rights which placed 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 · E2022-11-22 · tag F0657 — failed to keep the care plan current — patternDevelop 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 36 residents. The sample included 13 residents. Based on observation, record review, and interview, The facility failed to place interventions on the care plan to prevent falls for Resident (R) 9, and R12, failed to add interventions related to the positioning device for R1, and bowel management for R37. This placed the residents at risk for uncommunicated care needs. - The Electronic Medical Record (EMR) for R9 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required set up assistance with supervision for bed mobility, transfers, ambulation, had steady balance, and had no…
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 · E2022-11-22 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 36 residents. The sample included 13 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for five sampled residents. Resident (R) 9, R32, R22, and R26. This placed the residents at risk for complications related to poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R9 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required limited assistance of one staff for bathing and set up assistance with supervision for all other ADLs.…
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 before2022-11-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 Electronic Medical Record (EMR) for R9 recorded diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required set up assistance with supervision for bed mobility, transfers, ambulation, had steady balance, and had no functional impairment. The MDS further documented R9 had two injury falls and had a wander alarm (designed to help protect residents against elopement). R9's Quarterly MDS, dated 07/18/22, documented R9 had intact cognition and required set up assistance with supervision for bed mobility, transfers, ambulation, had steady balance, and had no functional impairment. The MDS further documented R9 had two…
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 · D2022-11-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 36 residents. The sample included 13 residents with one reviewed for positioning. Based on observation, interview and record review the facility failed to ensure proper positioning and utilize the positioning devicefor sampled Resident (R)1. This deficient practice placed the resident at risk for further decrease in range of motion. Findings included: - R1's Electronic Medical Record (EMR) documented a diagnosis of multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue, anxiety, depression). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10. The MDS documented R1 required supervision for eating and extensive assistance of two staff for all other activities of daily living…
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 · D2022-11-22 · 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 36 residents. The sample included 14 residents with three reviewed for bowel and bladder. Based on observation, interview, and record review the facility failed to provide catheter (tube inserted into the bladder to drain urine) care routinely, including monitoring urinary output as ordered and directed by the plan of care. This deficient practice placed R1 at risk for complications of urinary catheter use. Findings included: - R1's Electronic Medical Record (EMR) documented a diagnosis of multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue, anxiety, depression). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10. The MDS documented R1 required supervision for eating and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-22 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 36 residents. The sample included 13 residents, with three reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary dementia (progressive mental disorder characterized by failing memory and confusion) for Resident (R) 32, who had dementia related behaviors. This placed the resident at risk decreased quality of life and unmet needs. Findings included: - The Electronic Medical Record (EMR) for R32 documented diagnoses of dementia without behavioral disturbance and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R32 had severely impaired cognition and required supervision of one staff for transfers, ambulation, wandered daily and had unsteady gait. The MDS further documented R32 intruded on others, wandered to dangerous places one to three times per week, had a motion sensor, and a wander/elopement alarm. The Care Plan, dated 11/16/22 documented R32's behaviors have an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-22 · 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 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide routine pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs for one of six reviewed for unnecessary medications, when staff failed to reorder R26's lidocaine 5% patch(a soft, stretchy adhesive patch containing 5% lidocaine (700 mg), daily, for the topical treatment of pain). This placed the resident at risk for ineffective medication regimen. Findings included: - R26's Electronic Medical Record (EMR) documented the resident had diagnoses of Parkinson's (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), chronic (persisting for a long period, often for the remainder of a person's lifetime) pain, osteoarthritis (chronic arthritis without inflammation), age related physical debility, and pain in left and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-22 · 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
The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to the facility failed to ensure Resident (R)190's medication administration was free from significant errors when staff crushed an extended-release medication. This placed the residents at risk for the medications being improperly released. Findings included: - On 11/21/22 at 09:38 AM, observation revealed Certified Medication Aide (CMA) T, during medication administration, crushed R190's metoprolol succinate (medication used to lower blood pressure), 25 milligram (mg,) extended release (ER)and placed it in a medication cup by itself. Observation revealed CMA T checked the resident's pulse and blood pressure and stated they were within parameters, then placed the metoprolol in a medication cup with the other medications in clear thickened liquid and administered the medications to R190. On 11/21/22 at 12:58 PM, CMA T verified he had crushed the above medication and was unaware he was not supposed to. CMA T pulled up R190's Electronic…
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 · D2022-11-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to maintain Resident (R) 15's oxygen tubing, nasal cannula and breathing treatment mask in a sanitary fashion which placed R15 at risk for respiratory illness. Findings included: - On 11/17/22 at 09:33 AM observation revealed R15's nasal cannula oxygen tubing had been uncovered laying on the floor next to the oxygen canister. On 11/17/22 at 11:42 AM observation revealed R15's breathing treatment mask sat on the bedside table uncovered. On 11/22/22 at 11:30 AM observation revealed R15's oxygen tubing and nasal cannula uncovered draped over the oxygen concentrator. On 11/22/22 at 11:34 AM Licensed Nurse I verified the observation of the oxygen tubing, nasal canula and breathing treatment mask had been uncovered and should have been stored in a plastic bag. On 11/22/22 at 12:22 PM Administrative Nurse D stated staff should store oxygen cannula and breathing treatment mask in a plastic bag or some kind of storage container. The facility'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.
- No harm found · C2022-11-22 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to post the previous state inspection information in a location accessible to residents and visitors, which placed the residents at risk for impaired information. Findings included: - On 11/21/22 at 03:21 PM Administrative Staff A stated the state agency inspection results were posted at the C Hall nurses station, which was under construction, and was not available to residents; the areas was blocked off since September 2022. Upon request the facility failed to provide a policy related to accessibility of state inspection results. The facility failed to post state inspection results accessible to residents during construction which placed the residents at risk of uninformed facility care report.
“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
$30,244 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $14,651 — penalty dated 2024-05-15
- $15,593 — penalty dated 2023-08-29
- Medicare payment denial — starting 2024-06-01 for 2 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 PRESBYTERIAN MANORS OF MID-AMERICA — 13 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 | 3 of 5 | 3.8 | -0.8 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 4 of 5 | 4.3 | -0.3 vs chain |
| Quality measures | 2 of 5 | 3.2 | -1.2 vs chain |
The other 12 homes this chain runs (chain average 3.8★, 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 |
|---|---|---|---|---|
| PRESBYTERIAN MANORS INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/30/1989 |
| SHOGREN, BRUCE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 04/26/2004 |
| SIEPELMEIER, SUSAN | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 09/29/2014 |
| BONNEY, ROBERT | Individual | CORPORATE DIRECTOR | — | since 04/23/2019 |
| BRENNECKE, GARY | Individual | CORPORATE DIRECTOR | — | since 07/01/2015 |
| COOK, JAMES | Individual | CORPORATE DIRECTOR | — | since 07/01/2012 |
| GOODWIN, JOHN | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| HARRIS, DANIEL | Individual | CORPORATE DIRECTOR | — | since 07/01/2019 |
| MCKELL, ELIZABETH | Individual | CORPORATE DIRECTOR | — | since 07/01/2012 |
| MORRISON, AARON | Individual | CORPORATE DIRECTOR | — | since 07/01/2015 |
| NELSON, ELEANOR | Individual | CORPORATE DIRECTOR | — | since 07/01/2010 |
| HIND, SHERRY | Individual | CORPORATE OFFICER | — | since 07/01/1989 |
| MILLER, JOAN | Individual | CORPORATE OFFICER | — | since 09/01/1997 |
| OWENS, MELANIE | Individual | CORPORATE OFFICER | — | since 07/10/2017 |
| TAYLOR, WILLIAM | Individual | CORPORATE OFFICER | — | since 07/01/2015 |
| PRESBYTERIAN MANORS OF MID-AMERICA INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/30/1989 |
CMS files one row per role, so the 18 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $682K 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 2024. 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, FY2024). 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 175304. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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.