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Frankfort Community Care Home

510 N Walnut Street, Frankfort, KS 66427 · Non profit - Corporation · 40 certified beds · (785) 292-4442 Medicare & Medicaid certified

Call the home — (785) 292-4442 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2024Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$19,386 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $19,386 in federal fines (most recent 2025-11-17)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1017 Broadway Ste 7 · (785) 562-3609 · Call to confirm hours
Pharmacy
17 Public Sq · (785) 363-7444 · Call to confirm hours
Grocery
106 W 5th St · (785) 363-7288 · Call to confirm hours
Park
104 E 2nd St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased22.1%17.9%15.4%worse
Long-stay residents who lose too much weight7.5%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder1.0%1.6%0.9%worse
Long-stay residents with a urinary tract infection2.9%2.9%2.0%worse
Long-stay residents with depressive symptoms4.5%6.5%6.5%better
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 injury15.2%4.3%3.3%worse
Long-stay residents whose ability to walk worsened24.9%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.8%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine88.5%95.5%95.3%typical
Long-stay residents with pressure ulcers4.1%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control26.9%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table27.3%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine19.0%73.8%79.4%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

10.1%U.S. median 10.7%
Went back to hospital
0.23U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a 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 SNF10.1%CMS range 6.1–15.810.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in 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 SNFs0.871.02Oct 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

0.81
RN hours/ resident / day
0.55
LPN hours/ resident / day
2.58
Aide hours/ resident / day
3.93
Total nurse hours/ resident / day
0.50
RN hoursweekends
57.1%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 40 beds and averages 27.3 residents a day — about 68% occupied, or roughly 13 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.42 hrs/resident/day on weekends vs 4.14 on weekdays — 17% thinner on weekends. RN hours go from 0.93 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%.

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

Inspection trend

14
deficiencies at the latest standard inspection (2025-11-17)
11
at the previous standard inspection (2024-01-17)

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.

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.

33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-11-17 · 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 identified a census of 27 residents, with one resident reviewed for elopement (when a resident leaves the premises or a specific safe area without authorization and/or necessary supervision). Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R) 7, whom the facility identified the resident as at high risk for wandering. On 08/26/25 at approximately 07:41 PM, R7 exited the South delayed-egress door in her wheelchair, which alarmed, and no staff responded to the sounding alarm. R7 exited the facility unsupervised, mobilized to the driveway, and continued to independently propel herself in a wheelchair across the concrete driveway into the city street, traversing approximately 200 feet. At approximately 07:42 PM, License Nurse (LN) H exited the nurse's station and looked down the South Hall at the door with the sounding alarm, then re-entered the nurse's station. At approximately 07:43:53 PM…

    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
  • Immediate jeopardy · Jcited before2024-04-09 · 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 identified a census of 33 residents with three residents reviewed for elopement. Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent cognitively impaired Resident (R) 1, identified at high risk for elopement, from eloping through a facility window. On 03/30/24 at 03:00 PM, R1 sat at the end of the North hall and looked out the window. R1's home was visible from the North hall window. At 03:05 PM, R1's neighbor in the community noticed R1 walking towards the resident's home. A little while later, the neighbor noticed R1 sitting on his porch at his home and at 03:40 PM, the neighbor called the facility and alerted Administrative Nurse D to R1's location. Upon investigation, Administrative Nurse D noted the window at the end of the North hall was missing the screen, which was observed on the ground outside the facility. It appeared R1 removed the screen and stepped through the full-size window. R1 wore a Wander Guard (a bracelet that sets…

    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 · Fcited before2025-11-17 · 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 27 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 27 residents who reside in the facility and received meals from the facility kitchen.Findings included:- On 09/29/25 at 11:00 AM, observation of the noon meal consisted of honey pot roast, potatoes, cabbage, and pineapple cake. Dietary Staff (DS) BB was observed overseeing the preparation of the noon meal. DS BB would also assist staff with taking meal trays to the residents.On 09/29/25 at 08:45 AM, DS BB stated she had just started a couple of months ago, was not certified, or started taking the classes yet.On 09/30/25 at 03:20 PM, Administrative Nurse D verified DS BB was not certified.The facility's Dietitian policy, dated July 2025, documented that a qualified, competent, and skilled dietitian would help oversee the food and nutrition services in the facility. If a dietitian was not employed full-time (35 hours or more per week), a director of food and nutrition services would be designated. This individual…

    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 · Fcited before2025-11-17 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 27 residents. Based on observation, record review, and interview, the facility kitchen staff failed to take the food temperatures before serving the noon meal.Findings included: - On 09/30/25 at 11:15 AM, Dietary Staff (DS) CC prepared the noon meal of pork chop with gravy, mashed potatoes, and broccoli. Observation revealed DS CC ground three porkchops in the robot coupe (a commercial food processor) and placed the plastic 3-quart bowl in the steam table. DS CC made a plate of the regular meal for three residents and served them. DS CC did not obtain the food temperatures. When asked if she was going to temp the food before she served anyone else, DS CC stated she had already obtained the food temperatures earlier but had not documented it. DS CC stated she would take the food temperatures again. DS CC was questioned regarding taking the food temperatures of the pureed meal and ground meat. Continued observation revealed DS CC took the temperature of the main meal and also the pureed meal, but not the ground pork chop. Continued observation revealed DS…

    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 · Fcited before2025-11-17 · 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 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food safety, and failed to consistently document sink and bucket PPM (parts per million) sanitation on the facility's PPM log (a record keeping document used in food service to monitor the concentration of sanitizing solutions in sinks and other equipment to ensure food safety).Findings included:- On 09/29/25 at 08:15 AM, during the initial kitchen tour, the daily temperature logs for the seven freezers and three refrigerator logs for September 2025 lacked documentation of daily temperatures.Freezer 1 in the AM: 3 out of 30 opportunitiesFreezer 1 in the PM: 8 out of 30 opportunitiesFreezer 2 in the AM: 2 out of 30 opportunitiesFreezer 2 in the PM: 9 out of 30 opportunitiesFreezer 3 in the AM: 2 out of 30 opportunitiesFreezer 3 in the PM: 10 out of 30 opportunitiesFreezer 4 in the AM: 2 out of 30 opportunitiesFreezer 4 in the PM: 10 out of 28 opportunitiesFreezer…

    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 · F2025-11-17 · tag F0868 — widespread
    Have 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 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure their Medical Director attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings. Findings included:- On 09/30/25 at 02:30 PM, the facility provided QAA committee attendance rosters for 03/01/24, 10/23/24 (6 months no meeting), 01/22/25, and 04/16/25 until the present (6 months no meeting), and in which the medical director had been present for the three meetings but had not been present for the 01/22/25. The facility only provided documentation for three quarters of the four required for the year 2024 to 2025.On 09/30/24 at 04:30 PM, Administrative Staff A verified the QAA meetings should be held quarterly and were to include the medical director and verified the lack of quarterly meetings, and verified the medical director did not attend some of the meetings.The facility's Quality Assurance and Performance Improvement policy, dated August 2025, documented the quality assurance and performance…

    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 · Fcited before2025-11-17 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 2.Findings included:- On 09/30/25 at 08:20 AM, observation revealed R2 sat in a wheelchair in his room. Licensed Nurse (LN) G and Consultant GG entered R2's room and asked R2 if they could change the dressing on his right outer ankle. R2 replied, Sure. Observation revealed all items needed for dressing change were on a barrier on R2's bed. Consultant GG and LN G applied gloves, Consultant GG removed R2's sock and dressing on his outer ankle, to reveal a scant amount of green drainage on the dressing, measured the wound area, discarded the dressing in a trash can, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0582 — isolated
    Give 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 27 residents. The sample included 12 residents, with three residents reviewed for the Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on the record review and interview, the facility failed to provide the CMS Form 10123, Advanced Beneficiary Notice (ABN), to the resident or their representative for Residents (R) 4. Findings included:- The Medicare ABN form 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 options for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand that if Medicare does not pay, I will be responsible for payment, but I 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. This placed the residents at risk of uninformed decisions about their skilled services. The facility lacked documentation staff provided R4…

    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 · D2025-11-17 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents, with three reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO- a public official who works to resolve resident issues in nursing facilities) for two residents. Resident (R) 4 and R5 and failed to provide R5 with written information regarding the facility's bed hold policy when they were transferred to the hospital.Findings included:- The Electronic Medical Record (EMR) for R4 documented diagnoses of orthostatic hypotension (blood pressure dropping with change of position), vertigo (sensation of spinning and dizziness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and left artificial hip joint (a man-made implant that replaces damaged or diseased portions of the natural hip to restore function and relieve pain).R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-17 · 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 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 14 for lymphedema (swelling caused by accumulation of lymph) and R6 for his diagnosis of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress).Findings included:- The Electronic Medical Record (EMR) for R14 documented diagnoses of lymphedema, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, or irrational fear), and diabetes mellitus (DM- when the body cannot use glucose, not enough…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide necessary respiratory care and services for Resident (R) 14, when staff stored the uncovered nebulizer (turns liquid medication into a mist so that you can inhale it into your lungs) mask on top of the nebulizer machine, and failed to ensure R14's nasal cannula (NC - a thin hollow tube that assists in providing supplemental O2) was appropriately stored when not used.Findings included:- The Electronic Medical Record (EMR) for R14 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, or irrational fear),…

    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 before2025-11-17 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 27 residents. The sample included 12 residents, with three residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 6 posttraumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization, and major depressive disorder (MDD- major mood disorder that causes persistent feelings of sadness). Findings included:- R6's Electronic Medical Record (EMR) documented diagnoses of posttraumatic stress disorder, major depressive disorder, and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The Annual Minimum Data…

    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
Show the remaining 21 citations
  • Potential for harm · Dcited before2025-11-17 · 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 27 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medication per the physician-ordered parameters for Resident (R) 4.Findings included:- The Electronic Medical Record (EMR) for R4 documented diagnoses of orthostatic hypotension (blood pressure dropping with change of position), vertigo (sensation of spinning and dizziness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and nonrheumatic aortic valve stenosis (heart valve failure).R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition. R4 required partial staff assistance for oral hygiene, upper body dressing, and transfers. R4 was independent with eating, personal hygiene, and mobility. The MDS further documented R4 received antidepressant (a class of medications used to treat mood disorders), opioid (a class 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 27's insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. Findings included: - On [DATE] at 09:10 AM, observation of the facility medication treatment cart revealed R27's Lantus (long-acting insulin) flex pen was not labeled with an opened date or an expired date.On [DATE] at 08:15 AM, License Nurse G verified the nurses should label and date the insulin flex pens with the date opened.On [DATE] at 08:00 AM, Administrative Nurse D verified the nurse should label and date the insulin flex pens with the date opened.Medlineplus.gov directs open, unrefrigerated Lantus can be used within 28 days; after that time, they must be discarded.The facility's Medication Labeling and Storage policy, dated 2001, documented labeling of medications and biologicals dispensed by the pharmacy was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 27 residents. The sample included 12 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 1. Findings included: - R1's Electronic Medical Record (EMR) revealed diagnoses of senile degeneration of the brain (the gradual decline in cognitive function and brain structure that occurs with aging), dementia (a progressive mental disorder characterized by failing memory and confusion), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and basal cell carcinoma (skin cancer that forms in the basal cells of your skin) of the skin.R1's Significant Change Minimum Data Set (MDS), dated [DATE],…

    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 · D2024-05-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to protect Resident (R) 1 from intimidation and abuse. This placed R1 at risk for impaired psychosocial well-being and ongoing abuse. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and high blood pressure. The admission Minimum Data Set (MDS), dated [DATE] documented the Brief Interview for Mental Status (BIMS) could not be completed because R1 was rarely/never understood. The MDS documented R1 had short-term and long-term memory problems and had severely impaired cognition. The MDS documented R1 required substantial/maximum assistance with all her activities of daily living (ADLs) except eating. The MDS documented R1…

    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 · Fcited before2024-01-17 · 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 — the official record, unedited, may be distressing

    The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 29 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for impaired nutrition. Findings included: - On 01/10/24 at 08:30 AM, observation revealed Dietary Staff BB was in the kitchen and oversaw the preparation of the breakfast meal. On 01/10/24 at 08:35 AM, Dietary Staff BB verified she was not a certified dietary manager. On 01/11/24 at 09:00 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. Upon request, the facility did not provide a policy for dietary managers. The facility failed to employ a full-time certified dietary manager for 29 residents who resided in the facility. This placed the residents at risk for inadequate nutrition.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-17 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to meet the nutritional needs of residents in accordance with established national guidelines, placing the residents at risk for unmet nutritional needs. Findings included: - On 01/10/24 at 11:30 AM, observation of the lunch meal revealed the kitchen served ham and beans and cornbread. On 01/10/24 at 11:40 AM, a review of the menu for the meal to be served at lunch stated ham and beans, cornbread and two vegetables were to be served for the meal. On 01/10/24 at 11:50 AM, Dietary Staff (DS) CC verified he did not prepare any vegetables to serve with the meal. On 01/10/24 at 12:30 PM, DS BB verified the menu for the lunch meal on 01/10/24 was to include two vegetables. DS BB verified the vegetables were not prepared for the meal. The facility's Menus policy dated 10/2017, documented a menu is to be approved each month by a registered dietician. If a food group is missing from a resident's daily diet the resident is provided an alternate…

    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 · Fcited before2024-01-17 · 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 — the official record, unedited, may be distressing

    The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to check sanitization for the dishwasher, and the three-compartment sink in the facility's only kitchen. This placed the residents at risk for foodborne illness. Findings included: - On 01/11/24 at 09:00 AM, observation in the facility kitchen revealed a three-compartment sink. Further observation revealed a dishwasher. On 01/11/24 at 09:15 AM, Dietary Staff (DS) BB verified the facility did not check sanitization for the three-compartment sink or the dishwasher. DS BB verified there were no sanitization strips available to check sanitization for the sink or dishwasher. The facility's Sanitization policy, dated 11/2022, documented dishwashing areas and sink sanitation is to be tested daily and recorded. Using appropriate sanitization strips. The facility failed to check sanitization for the dishwasher and the three-compartment sink. This placed the residents at risk for foodborne illness.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-17 · 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

    The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to provide Resident (R) 16 with dignity and respect during care, placing the resident at risk for an undignified experience. Findings included: - On 01/11/24 at 08:00 AM, observation revealed R16 sat on a dining chair at the dining table eating breakfast. Further observation revealed Licensed Nurse (LN) H obtained a blood sample from R16's finger using a blood glucose meter to check R16's blood glucose. Continued observation revealed LN H pulled up R16's shirt and exposed her stomach, then administered an insulin injection (a hormone that lowers the level of glucose in the blood) while the resident ate her breakfast. Further observation revealed eight other residents in the dining room. On 01/11/24 at 08:20 AM, observation revealed R16 sat on a dining chair at the dining table eating breakfast. Further observation revealed Certified Medication Aide (CMA) M used a blood pressure cuff and obtained R16's blood pressure while she ate…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 29 residents. The sample included 12 residents. Based on record review and interview the facility failed to ensure staff identified concerning behaviors as potential allegations of abuse and/or mistreatment and failed to report to the facility administrator as required. This placed the resident at risk for unidentified and ongoing abuse and/or mistreatment. Findings included: - Certified Medication Aide (CMA) N's notarized Witness Statement dated 01/11/24, documented CMA N had observed Licensed Nurse (LN) G yell at Resident (R)7 prior to 01/11/24 when R7 had two drinks at the dining room table. CMA N documented she heard LN G tell the kitchen staff R7 could only have small drinks and could not have more until R7 drank what she had. Certified Nurse Aide (CNA) O's notarized Witness Statement documented that approximately two weeks prior to 01/11/24, R19 approached CNA O very upset, and reported LN G was not nice to her. CNA O documented LN G, in the nurse-to-nurse report (which did not include the resident) said R19 was being a [expletive] and LN G said…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-17 · 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 29 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a comprehensive care plan to include Resident (R)9's diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). This deficient practice placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - R9's Electronic Medical Record (EMR) documented she had a diagnosis of diabetes mellitus. R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition and required moderate assistance for bed mobility, transfers, and locomotion. The MDS further recorded R9 received insulin (a hormone medication to control blood sugar) injections daily. R9's EMR lacked a comprehensive care plan that addressed the use of insulin, signs or symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-17 · 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 29 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to update Resident (R)23's Care Plan with interventions for staff to follow regarding care of her fractured wrist. The facility failed to update R26's Care Plan with interventions for staff to follow regarding her post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). These failures placed the residents at risk for inadequate care due to uncommunicated care needs. Findings included: - R23's Electronic Medical Record (EMR) documented R23 had a diagnosis of a fracture of the lower end of her left radius (one of the bones going from the wrist to the elbow). R23's Quarterly Minimum Data Set (MDS), dated [DATE], documented R23 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R23 was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-17 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 29 residents. The sample included 12 residents, of which two were reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment for Resident (R)26, to identify any history of trauma This placed the resident at risk for unmet behavioral and mental health needs. Findings included: - R26's Electronic Medical Record (EMR) documented R26 had diagnoses of mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), alcoholic myopathy (condition involving muscle weakness and loss of muscle due to abnormal breakdown of muscle tissue) and cognitive communication deficit. R26's admission Minimum Data Set (MDS), dated [DATE], documented R26 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS documented R26 required maximal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-17 · 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 29 residents. The sample included 12 residents, of which two were reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide adequate medical social services to meet Resident (R) 26's mental and behavioral health needs. This placed the resident at risk for decreased quality of care and life. Findings included: - R26's Electronic Medical Record (EMR) documented R26 had diagnoses of mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), alcoholic myopathy (condition involving muscle weakness and loss of muscle due to abnormal breakdown of muscle tissue) and cognitive communication deficit. R26's admission Minimum Data Set (MDS), dated [DATE], documented R26 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS documented R26 required maximal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 29 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication for use, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)12 and R20. This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications. Findings included: - R12's Electronic Medical Record (EMR) documented R12 had diagnoses of depressive disorders ((a mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (a progressive mental disorder characterized by failing memory, and confusion) with behavioral disturbance. R12's Annual 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-17 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 29 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to follow a recipe while preparing two residents' pureed diets. This placed the residents at risk for impaired nutrition. Findings included: - On 01/11/24 at 10:30 AM, Dietary Staff (DS) CC stated the facility had two residents with pureed diets. DS CC poured zucchini pieces from a pan into the blender container and then blended. DS CC then took a can of thickener, poured thickener into the blender, and blended without following a recipe. On 01/11/24 at 10:40 AM, DS CC verified she had not followed a recipe and stated was unsure if there was a pureed recipe. On 01/17/24 at 09:00 AM, DS BB stated staff should follow a recipe when preparing residents' pureed diet. The facility's Therapeutic Diets policy, dated 10/2017, documented the food and nutrition services department will be responsible for preparing and serving the correct consistency of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-07-25 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R13's Electronic Medical Record (EMR) documented R13 had diagnoses of UTI., urinary incontinence and urine retention (when the bladder does not empty all the way or at all). R13's Significant Change Minimum Data Set (MDS), dated [DATE], documented R13 required total staff assistance with activities of daily living (ADLs) except supervision with eating. The MDS documented R13 had an indwelling urinary catheter. R13's Incontinence and Indwelling Catheter Care Area Assessment CAA, dated 05/27/22, documented R13 had urinary retention and urinary catheter. R13's ADLs Care Plan, revised 6/01/21, documented R13 required staff assistance for toileting and she had a urinary catheter. The care plan instructed staff to position the catheter bag and tubing below the level of R13's bladder and away from the entrance room door. It further directed staff to monitor and report to the physician signs symptoms of discomfort on urination and frequency, and signs symptoms of UTI. On 07/20/22 at 9:55 AM, observation revealed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-25 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility had a census of 26 residents. The sample included 12 residents with one reviewed for completion of a Quarterly Minimum Data Set (MDS-an assessment which contains resident specific information for payment and quality measure purposes). The facility failed to complete the Quarterly MDS for Resident (R) 2. This placed the resident at risk for unidentified needs. Findings included: - On 07/19/22 review of the Electronic Medical Record (EMR) documented a completed Quarterly MDS on 03/01/22. The EMR lacked a completed Quarterly MDS for 06/01/22. On 07/20/22 at 11:00 AM, Administrative Nurse D verified the Quarterly MDS for R2 was not completed and should have been done. The facility's policy, dated 07/2017, stated the facility will conduct timely resident assessments in accordance with current federal and state time frames, which is every 90 days. The facility failed to complete R2's Quarterly MDS, placing the resident at risk for unidentified care needs.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-25 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to assess one of 12 sampled residents' cognition, Resident (R)16 on the Minimum Data Set (MDS).This placed the resident at risk for an inaccurate care plan and unmet care needs. Findings included: - R16's Electronic Medical Record (EMR) documented the resident had diagnoses Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). R16's Quarterly MDS, dated 06/07/22, documented R16's Brief Interview for Mental Status (BIMS) section was not assessed and no staff interview was completed. The MDS documented the resident required extensive staff assistance with activities of daily living (ADLs) except limited staff assistance with personal hygiene, and supervision with eating. R16's Cognition Care Plan, revised 06/10/22, documented…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 26 residents. The sample included 12 residents with one reviewed for urinary catheter. Based on observation, record review, and interview the facility failed to provide appropriate treatment and services to prevent urinary tract infections, when staff failed to change gloves while providing Resident (R) 13, who had history of urinary tract infections (UTIs-infection of any part of the urinary system) and a urinary catheter (tube inserted into the bladder to drain urine into a collection bag), perineal and catheter care. Staff continued to provide care with soiled gloves. The facility staff failed to ensure R13's urinary catheter bag remained off contaminated surfaces. This placed R13 at increased risk for recurring UTI and related complications. Findings included: - R13's Electronic Medical Record (EMR) documented R13 had diagnoses of UTI, urinary incontinence and urine retention (when the bladder does not empty all the way or at all). R13's Significant Change 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 · D2022-07-25 · 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 26 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 20's blood glucose readings greater than 250 milligram (mg)/deciliter(dl), and the lack of administration of physician ordered insulin (medication used to lower blood sugars) for these blood sugars. This placed the resident at risk for hyperglycemic (increased blood sugar levels) side effects. Findings included: - R20's Electronic Medical Record (EMR) documented the resident had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), R20's Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had short- and long-term memory problems 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-25 · 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 26 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure staff administered physician ordered Humalog (fast acting insulin medication) insulin (medication used to lower blood glucose) for Resident (R) 20's blood glucose readings greater than 250 milligram (mg)/deciliter(dl). This placed the resident at risk for hyperglycemic (increased blood sugar levels) side effects. Findings included: - R20's Electronic Medical Record (EMR) documented the resident had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), R20's Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had short- and long-term memory problems and severe cognitive impairment. The MDS documented R20…

    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

$19,386 in federal fines across 2 penalties.

  • $11,193 — penalty dated 2025-11-17
  • $8,193 — penalty dated 2024-04-09

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 GRACE TEAM SERVICES — 9 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 1 of 52.6-1.6 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 4 of 54.2-0.2 vs chain
Quality measures 1 of 51.7-0.7 vs chain
The other 8 homes this chain runs (chain average 2.6★, 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 / managerTypeRoleSince
BERGES, DANIELIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2025
LADNER, CONNIEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2025
SURDEZ, MERICAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2025
ZIMMERLING, CHARLOTTEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2025
ZIMMERLING, WALTIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2025
KEE, MICAHIndividualCORPORATE DIRECTORsince 01/01/2024
STEVENS, HALEYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2021
FRANKFORT COMMUNITY CARE HOME, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/1997
GRACE TEAM LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2021
GRACE, RYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2021
HUEBERT, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2021
ZIDEK, NANCYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 23 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$3.0M
Net patient revenuemost recent cost report
-9.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 56%Medicare 8%Other / private 36%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$318per resident / day
operating cost
$9,668per month
≈ monthly operating cost
$291per 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 175417. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-17, 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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