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Medicalodges Frontenac

206 S Dittman Street, Frontenac, KS 66763 · For profit - Corporation · 55 certified beds · (620) 231-7340 Medicare & Medicaid certified

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1 immediate-jeopardy citation$16,858 in federal fines
Insights

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

Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,858 in federal fines (most recent 2024-04-18)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (56%) 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) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
608 Willard St · (620) 231-8849 · Call to confirm hours
Pharmacy
3011 N Michigan St · (620) 231-2681 · Call to confirm hours
Grocery
Aldi0.9 mi
3109 N Broadway St · (855) 955-2534 · Call to confirm hours
Park
907 W McKay 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 held steady at 1 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 rating1★
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 increased14.8%17.9%15.4%typical
Long-stay residents who lose too much weight2.5%4.9%5.4%better
Long-stay residents with a catheter left in their bladder0.6%1.6%0.9%better
Long-stay residents with a urinary tract infection5.6%2.9%2.0%worse
Long-stay residents with depressive symptoms7.1%6.5%6.5%typical
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 injury2.7%4.3%3.3%better
Long-stay residents whose ability to walk worsened20.5%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication36.1%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine94.6%95.5%95.3%typical
Long-stay residents with pressure ulcers9.3%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control30.0%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table34.4%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better

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.

44.6% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.6%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
0.16U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.6%CMS range 29.9–62.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 5.9–15.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at 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 SNFs1.091.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
56.3%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 55 beds and averages 47.4 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.

Weekend coverage: total nurse staffing is 3.53 hrs/resident/day on weekends vs 4.22 on weekdays — 16% thinner on weekends. RN hours go from 0.55 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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

10
deficiencies at the latest standard inspection (2024-11-18)
8
at the previous standard inspection (2023-02-08)

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2024-04-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 reported a census of 33 residents. The sample included three residents reviewed for transfers with mechanical lifts. Based on observation, interview, and record review, the facility failed to ensure adequate staff to safely transfer residents, in accordance with professional standards, Occupational Safety and Health Administration (OSHA) guidelines, Food and Drug Administration (FDA) guidelines, and manufacturers recommendations, with use of a mechanical lift. The facility identified eight residents who required a full body mechanical lift and four residents who required a sit-to-stand mechanical lift for transfers. Nursing staff reported they utilized the mechanical lifts for resident transfers, without a second staff member present, due to lack of staff availability to perform the transfers correctly. Interviews with six residents confirmed staff regularly did not utilize two staff members with mechanical lift transfers. This deficient practice placed these 12 residents in immediate jeopardy. (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · 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 reported a census of 38 residents with three residents reviewed for elopement. Based on interview, interview and record review, the facility failed to prevent one Resident (R)1 from exiting the facility, unattended. Findings included: - Review of Resident (R)1's electronic medical record (EMR) revealed a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) review of 13, indicating intact cognition. He had limitation in range of motion (ROM) on one side of his upper extremity and used a motorized wheelchair. He was independent in wheeling 150 feet in his wheelchair. The Functional Abilities Care Area Assessment (CAA), dated 02/02/25, documented the resident required substantial to maximal assistance of staff for transfers. The care plan, revised 02/25/25, lacked staff information regarding the resident being at risk for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-18 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 36 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for three of the five Certified Nurse Aides (CNA) reviewed, CNA R, CNA MM, and CNA NN. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: Certified Nurse Aide (CNA) R, hired 10/18/19, lacked an annual performance review in her personnel file. CNA MM, hired 12/15/22, lacked an annual performance review in her personnel file. CNA NN, hired 05/17/22, lacked an annual performance review in her personnel file. The facility's Employee Handbook, undated, included: In order to assist employees, improve their performance, and to identify the areas in which they excel and the areas in which they need to improve, the facility would complete annual performance evaluations. On 11/18/24 at 01:30 PM, Administrative Nurse D stated the staff's annual evaluations were not up to date. The facility failed to complete an annual…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-18 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 36 residents. Based on interview, and record review the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS), accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report weekend staffing for Quarters 1 2024 (October 1-December 31), Quarter 2 2024 (January 1-March 31) and Quarter 3 2024 (April 1- June 30). Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 1 2024 (October 1-December 31), Quarter 2 2024 (January 1-March 31) and Quarter 3 2024 (April 1-June 30), revealed excessively low weekend staffing. Review of the staffing schedules for the weekends revealed the staffing was the same as during the weekdays. On 11/18/24 at 03:30 PM, Administrative Staff A stated the PBJ reporting was inaccurate. The facility lacked a…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-18 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 36 residents. Based on observation, interview, and record review, the facility failed to provide a sanitary dressing change for Resident (R)5, failed to track and trend infections and causative organisms, and failed to store personal protective equipment (PPE) in a sanitary manner to prevent the spread of infection. Findings included: - Observation, on 11/14/24 at 08:13 AM, revealed Licensed Nurse (LN) G, provided a dressing change to Resident (R)5's stage three pressure ulcer (a deep wound that involves full-thickness tissue loss, but does not expose the bone, tendon, or muscle) on the residents left buttock. LN G placed the dressing supplies directly onto the resident's overbed table without prior sanitizing the table. LN G opened the large final dressing and placed the pieces of calcium alginate (a substance used to absorb drainage from wounds) and Santyl (a substance used to remove dead tissue and promote wound healing) on the opened package interior. LN G placed four by four-inch gauze directly on the overbed table and proceeded to use the four…

    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 · Ecited before2024-11-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 reported a census of 36 residents with 14 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to safely transfer two Residents (R) 15 and R 32 and failed to ensure chemicals were kept locked on one resident hall, which housed eight confused residents. Findings included: - Review of Resident (R) 15's Electronic Medical Record (EMR) revealed the following diagnoses: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and pain (physical suffering or discomfort caused by illness or injury). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. She was dependent on staff for sit to stand and chair to bed to chair transfers. The Functional Abilities Care Area Assessment (CAA), dated 05/27/24, documented the resident required total staff assistance of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 36 residents. Based on observation and interview, the facility failed to ensure a safe, sanitary, and homelike environment in two resident rooms and one hallway. Findings included: - Observation on 11/13/24 at 10:30AM, revealed a strong urine odor in the west hallway near a resident room and inside the resident room. Observation on 11/13/24 at 10:35 AM, revealed multiple arched black streaks on the wall beside a resident's bed on the west hall. Observation on 11/13/24 at 10:40 AM, revealed a resident room on the west hall with two yellow brown irregular circle like stains on the ceiling which measured approximately 10 inches. During the environmental tour on 11/18/24 at 12:24 PM, Administrative Staff A and Housekeeping Staff V confirmed the above. Administrative Staff A stated the resident's mattress may need replaced and the black streaks were due to the positioning bar scraping against the wall repetitively and may need to reposition the bed. Housekeeping Staff V stated she would notify maintenance of the ceiling stains. The facility policy…

    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 · D2024-11-18 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with 14 residents sampled, including one resident reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide Resident (R)14 a Bed Hold upon admission to an acute care hospital. Findings included: - Review of the R14's EMR, on 10/19/24, revealed the resident admitted to an acute care hospital with a diagnosis of a urinary tract infection (UTI-an infection in any part of the urinary system) and sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). The resident returned to the facility on [DATE]. Review of the resident's EMR lacked a signed bed hold related to the 10/19/24 hospitalization for R14. On 11/18/24 at 12:10 PM, Administrative Nurse D stated the facility did not obtain a signed bed hold for this resident when she admitted to the hospital, and stated they expected staff to have a bed hold signed each time a resident admitted to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure the development of a personalize comprehensive care plan for an optimal toileting program for Resident (R)22. Findings included: - Review of Resident (R)22's medical record revealed diagnoses that included cardiomyopathy (heart disease), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and history of urinary tract infections. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The resident was always incontinent of bowel and bladder. The resident received diuretics (medication to promote the formation and excretion of urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/17/24, revealed the resident required total to…

    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 before2024-11-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with 14 residents included in the sample, including three residents reviewed for Activities of Daily Living (ADL). Based on record review, interview and observation, the facility failed to shave Resident (R) 29 on a regular basis. Findings included: - Review of Resident (R)29's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a staff assessment for cognition, which revealed moderate cognitive impairment. He had no impairment in functional range of motion (ROM) and had no rejection of cares. He was dependent on staff for personal hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/10/24, documented the resident was unable to make his wants and needs known to staff. The Functional Abilities CAA, dated 08/10/24, documented the resident required moderate assistance with his ADL cares.…

    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 before2024-11-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with 14 residents selected for review, which included two residents reviewed for urinary incontinence. Based on observation, interview, and record review, the facility failed to ensure adequate toileting opportunities for Resident (R)22. Findings included: - Review of Resident (R)22's medical record revealed diagnoses that included cardiomyopathy (heart disease), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and history of urinary tract infections. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The resident was always incontinent of bowel and bladder. The resident received diuretics (medication to promote the formation and excretion of urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/17/24, revealed the resident required total…

    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 18 citations
  • Potential for harm · D2024-11-18 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 36 residents. Based on observation, interview, and record review, the facility failed to ensure staff followed the principles of antibiotic stewardship to ensure the residents received appropriate antibiotics for causative organisms. Findings included: - Review of Resident (R)22's medical record revealed diagnoses that included cardiomyopathy (heart disease), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and history of urinary tract infections. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The resident was always incontinent of bowel and bladder. The resident received diuretics (medication to promote the formation and excretion of urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/17/24, revealed the resident required total to substantial…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-18 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 33 residents. The sample included three residents reviewed for transfers with mechanical lifts. Based on observation, interview, and record review, the facility failed to ensure nursing personnel had the knowledge, competencies and skill sets to provide care to safely transfer residents, in accordance with professional standards, Occupational Safety and Health Administration (OSHA) guidelines, Food and Drug Administration (FDA) guidelines, and manufacturers recommendations, with use of a mechanical lift. The facility identified eight residents who required a full body mechanical lift and four residents who required a sit-to-stand mechanical lift for transfers. Nursing staff reported they utilized the mechanical lifts for resident transfers, without a second staff member present. Interviews with six residents confirmed staff regularly did not utilize two staff members with mechanical lift transfers. Findings included: - During an onsite survey from (04/17/24 and 04/18/24) a concern was identified that facility staff did not utilize two staff for…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34 residents with three selected for review for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to provide adequate bathing for two of the three sampled, who were dependent on staff for bathing services, Resident (R)1 and R3. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of contracture (abnormal permanent fixation of a joint or muscle) to left and right hand, aphasia (condition with disordered or absent language function), intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), and cognitive communication deficit. The Annual Minimum Data Set (MDS) dated [DATE] assessed R1 with a short-term and a long-term memory problem with severely impaired decision making. R1 did not reject care and was totally dependent on two or more staff for bathing. R1 had range of motion…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-02-08 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 38 residents. The review included five direct care staff who worked in the facility over a year. Based on record review and interview, the facility failed to complete an annual performance review for the five direct care staff reviewed to ensure adequate cares provided to the residents by these staff. Findings included: - On 02/08/23, review of the employment personnel files for five direct care staff revealed the failure to complete an annual performance review for each of the five direct care staff as follows: 1. Certified Nurse Aide (CNA) MM, hired on 11/01/14. 2. CNA NN, hired on 11/12/21. 3 .CNA S, hired on 01/09/14. 4 .CNA OO, hired on 05/12/14. 5. CNA PP, hired on 05/30/19. The above five direct care staff members' Annual Performance Evaluations, lacked indication of review by the supervisor to the employee. On 02/07/23 at 11:39 AM, Administrative Nurse D confirmed the performance evaluations for the above direct care staff lacked indication of review with the employees by the supervisor. Nurse D explained the facility should complete 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 38 residents with 14 residents sampled, including three residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide one dependent Resident (R)17 with adequate bathing opportunities to remain clean. Findings included: - Review of Resident (R)17's electronic medical record (EMR) revealed a diagnosis of contractures (abnormal permanent fixation of a joint). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. He required total assistance of one staff for bathing and had impairment in range of motion (ROM) of his upper and lower extremities. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/16/22, did not trigger for further review. The quarterly MDS, dated 10/08/22, documented the staff assessment for cognition revealed severe cognitive impairment. He required total…

    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 · D2023-02-08 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 38 residents with 14 residents sampled, including six residents reviewed for activities. Based on observation, interview, and record review the facility failed to provide an ongoing program of appropriate activities for one Resident (R)17, of the six sampled residents. Findings included: - Review of Resident (R)17's electronic medical record (EMR) revealed a diagnosis of intellectual disabilities (when there are limits to a person's ability to learn at an expected level and function in daily life). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. It was very important for him to listen to music he liked, do his favorite activities and to do things with groups of people. He required total assistance of two staff for transfers and had impairment in range of motion (ROM) on both sides of his upper and lower extremities. The Activities Care Area Assessment (CAA), dated 04/16/22, did not trigger for…

    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 · D2023-02-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 38 residents with 14 selected for review which included two residents reviewed for quality of care. Based on observation, interview and record review, the facility failed to provide sanitary wound dressing changes to prevent infections, for one resident (R)9 and failed to ensure comfortable and anatomical wheelchair positioning for the other resident (R)8, of the two sampled residents. Findings included: - Review of Resident (R)9's medical record, revealed diagnosis included diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and psychotic (any major mental disorder characterized by a gross impairment in reality testing) disorder with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment. The resident required extensive assistance for personal hygiene 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-08 · 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 reported a census of 38 residents with 14 residents sampled, including one resident reviewed for accidents. Based on observation, interview and record review, the facility failed to provide a safe transfer for the one sampled dependent Resident (R)32, to prevent accidents. Findings included: - Review of Resident (R)32's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. The resident required extensive assistance of two staff for transfers and had no impairment in functional range of motion (ROM). The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/27/23, did not trigger for further review. The quarterly MDS, dated 11/19/22, documented the staff assessment for cognition revealed severe cognitive impairment. The resident required…

    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 before2023-02-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 38 residents with 14 selected for review. The 14 sampled residents included one with resident reviewed for catheter/urinary tract infection. Based on observation, interview and record review, the facility failed to provide sanitary catheter care to one resident (R)8 to prevent urinary tract infections. Findings included: - Review of Resident (R)8's Physician Order Sheet, dated 12/01/22, revealed diagnoses included neuromuscular disorder of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-08 · 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 reported a census of 38 residents with 14 selected for review with five residents selected for review of medications. Based on observation, interview and record review, the facility failed to ensure two of the five residents, (Residents (R) 18 and 20) reviewed recieved medication for adequate bowel movements at least every three days and failed to ensure one of the five residents Resident (R)21 received blood pressure medication within the physician ordered parameters. Findings included: - Review of Resident (R)21's Physician Order Sheet, dated 12/01/22, revealed diagnoses included congestive heart failure (a condition with low heart output and the body becomes congested with fluid) and hypertension (elevated blood pressure). A Physician's Order, dated 12/31/21, instructed staff to administer Carvedilol (a medication used to treat heart failure and hypertension), 25 milligrams (mg), twice a day for hypertension. The physician instructed staff to hold the medication if the systolic blood pressure…

    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 · D2023-02-08 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 38 residents. Review of medication passes for nine residents with a total of 26 medications received, revealed two medication errors for one of the residents, resulting in a medication error rate of 7.7%. Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% when the observations resulted in a total medication error rate of 7.7%. Findings included: - Review of Resident (R) 31's Physician Order Sheet revealed the following orders: On 09/22/21, the physician instructed staff to administer Synthroid (a medication to replace a hormone made by the thyroid gland and required administration on an empty stomach) 75 micrograms (mcg), daily, for hypothyroidism (a condition characterized by decreased activity of the thyroid gland). On 06/24/22, the physician instructed staff to administer Lisinopril (a medication to lower blood pressure) 30 milligrams (mg) daily and hold for SBP ([top number] systolic blood pressure the pressure of the heart when pumping blood out) less than 100 or DBP ([second…

    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 · E2021-08-09 · tag F0761 — failed to label and store drugs safely — pattern
    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

    The facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to provide appropriate storage of medications related to the refrigeration of acidophilus (probiotic medication) after opening, in accordance with the directions on the label to refrigerate after opening, for four residents (R)40, R 36, R 26, and R 9 of the facility. Findings included: - Review of resident (R)40's undated Physician Orders, documented medication orders which included acidophilus, one tablet, three times a day, as a probiotic. On 08/05/21 at 09:15 AM, Certified Medication Aide (CMA) R removed the opened, partially used, stock medication bottle of acidophilus from the top drawer of the unrefrigerated medication cart. She removed the tablet from the bottle and administered the acidophilus medication to Resident (R)40. CMA R confirmed the acidophilus stored in the medication cart should be stored in the refrigerator after opening, as indicated on the manufacturer's medication label. Additionally, she stated she administered additional residents…

    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 · D2021-08-09 · 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 reported a census of 43 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to revise the care plan for one Resident (R)19 to include her restorative nursing program and her use of oxygen. Findings included: - The Order Summary Report, dated 06/09/21, included diagnoses of difficulty in walking and muscle weakness, shortness of breath, asthma (disorder of narrowed airways that caused wheezing and shortness of breath), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R19 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact. She required extensive assistance of one staff for walking in the corridor and did not receive any days of restorative therapy programs for walking. R19 received physical therapy five days and used a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents with 13 selected for review, including two residents reviewed for bathing. Based on observation, interview, and record review, the facility failed to assist one resident, Resident (R)20, who was dependent on staff for bathing, seven of 20 opportunities from 06/10/21 through 07/28/21. Findings included: - The Order Summary Report, dated 07/12/21, for Resident (R)20, included a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The admission Minimum Data Set (MDS), dated [DATE], assessed R20 with a Brief Interview of Mental Status (BIMS) score of 15, indicating she was cognitively intact. It was somewhat important to her to choose between a tub bath, shower, bed bath, or sponge bath and she was totally dependent on staff for bathing. The Activities of Daily Living [ADL] Care Area Assessment (CAA), dated 06/21/21, revealed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 reported a census of 43 residents with 13 selected for review, including one resident reviewed for restorative services. Based on observation, record review, and interview, the facility failed to provide Resident (R)19 her restorative ambulation program. Findings included: - The Order Summary Report, dated 06/09/21, included diagnoses of difficulty in walking and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R19 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact. She required extensive assistance of one staff for walking in the corridor and did not receive any days of restorative therapy programs for walking. R19 received physical therapy five days and used a wheelchair for mobility. The Annual MDS, dated 06/12/21, assessed R19 with the same BIMS score and no restorative program for walking. She walked in the corridor only once or twice with set up assistance from the staff and used a wheelchair and walker for mobility. R19…

    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 · D2021-08-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents with 13 selected for review including two residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to change the oxygen nasal cannula tubing as scheduled and failed to provide appropriate storage for the nasal cannula for one Resident (R)19. Findings included: - The Order Summary Report, dated 06/09/21, for Resident (R)19 included diagnoses of shortness of breath, asthma (disorder of narrowed airways that caused wheezing and shortness of breath), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R19 with a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition intact. She had shortness of breath or trouble breathing with exertion, when at rest, and when lying flat. R19 required oxygen therapy. The Annual 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 · Dcited before2021-08-09 · 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 reported a census of 43 residents with 13 selected for review including five residents reviewed for unnecessary medications. Based on record review and interview, the facility failed to monitor bowel functioning for one Resident (R)39 for constipation (difficulty passing stools) and provide medication ordered as needed. Findings included: - The Order Summary Report, dated 07/12/21, for Resident (R)39, included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and rectal prolapse (when the portion of the rectum bulges out of the anus). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R39 with a Brief Interview of Mental Status (BIMS) score of two, indicating severe cognitive impairment. She required extensive assistance of two staff for toilet use and was continent of bowels. The Significant Change MDS, dated 07/24/21, assessed R39 with a BIMS score of zero, indicating severe cognitive impairment. She continued to be continent of bowels 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
  • No harm found · C2025-03-20 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 38 residents. Based on observation, record review and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, daily, for the 38 residents who reside in the facility. Findings included: - Review of the facility's Daily Staffing Sheets, from 01/01/25 through 03/19/25, revealed the actual hours worked had not been completed on the daily staffing sheets. On 03/20/25 at 03:07 PM, Administrative Nurse D, stated she noticed on 03/20/25 that the forms did not include actual hours worked, as required The facility policy for Benefits Improvement Protection Act (BIPA) Nurse Staff Posting, revised 12/19, included: The actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care by shift will be recorded on the Daily Staff Posting form.

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

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

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

Fines & penalties

$16,858 in federal fines across 1 penalty.

  • $16,858 — penalty dated 2024-04-18

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

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

RatingThis homeChain avg
Overall 1 of 52.7-1.7 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 1 of 53.6-2.6 vs chain
Quality measures 1 of 52.8-1.8 vs chain
The other 17 homes this chain runs (chain average 2.7★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
MEDICALODGES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 03/01/2013
BUTLER, RICHARDIndividualCORPORATE DIRECTORsince 03/01/2013
COX, GARENIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 03/01/2013
DOLL, GAYLEIndividualCORPORATE DIRECTORsince 03/01/2013
GROVER, BRIDGETIndividualCORPORATE DIRECTORsince 06/01/2025
HINES, SCOTTIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; TRUSTEE OF THE SNFsince 03/01/2013
LAGER, SHANNONIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/23/2018
MARSHALL, CAROLIndividualCORPORATE DIRECTORsince 03/01/2013
OTT, RONIndividualCORPORATE DIRECTORsince 03/01/2013
CHRISTMAS, KEVINIndividualCORPORATE OFFICERsince 03/27/2025
COOVER, TERESAIndividualCORPORATE OFFICERsince 09/21/2017
DANIELS, JANAIndividualCORPORATE OFFICERsince 03/27/2025
DILLON, WILLIAMIndividualCORPORATE OFFICERsince 09/12/2022
FISHER, KRISTYNIndividualCORPORATE OFFICERsince 03/28/2024
KELLY, ELIZABETHIndividualCORPORATE OFFICERsince 03/27/2025
LANTZ, KATHLEENIndividualCORPORATE OFFICERsince 03/01/2013
LISTWAN, SAMANTHAIndividualCORPORATE OFFICERsince 06/05/2017
MCBRIDE, TRAVISIndividualCORPORATE OFFICERsince 03/01/2013
ROHLING MCCORD, CATHERINEIndividualCORPORATE OFFICER; TRUSTEE OF THE SNFsince 03/01/2013
SCHERTZ, AMBERIndividualCORPORATE OFFICERsince 10/05/2023
WAECHTER HARMON, LORIIndividualCORPORATE OFFICERsince 04/01/2019
CITY OF FRONTENAC, KANSASOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2013
RICKS, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/16/2017
TAYLOR, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/29/2025

CMS files one row per role, so the 34 rows in the source record cover these 24 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.

$3.3M
Net patient revenuemost recent cost report
-16.4%
Operating marginrevenue minus expenses
$165K
Related-party expense4% of expenses

This home reported $165K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$283per resident / day
operating cost
$8,605per month
≈ monthly operating cost
$243per 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 175363. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-18, 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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