Galena Nursing & Rehab Center
1220 E 8th Street, Galena, KS 66739 · For profit - Corporation · 45 certified beds · (620) 783-1383 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0609, F0610) — most recent Mar 2026
- inspectors recorded 3 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $21,645 in federal fines (most recent 2026-03-30)
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (66%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 fell from 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.3% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.5% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.7% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.6% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.2% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.5% | 23.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.9% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.8% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.5% | 18.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.5% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.4% | 73.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 32.2% | 22.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 21.7% | 11.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.29 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.89 | 2.13 | 1.80 | 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.
67.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 62 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 67.9%CMS range 57.6–78.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 6.5–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 43.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 92.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.7–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 45 beds and averages 37.2 residents a day — about 83% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 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 3.24 hrs/resident/day on weekends vs 4.05 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.73 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 66% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.
- Immediate jeopardy · J2026-03-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure Resident (R) 1 remained free from abuse. On 03/21/26 at around 10:30-11:00 PM Certified Nurse Aide (CNA) M identified bruising on R1's right leg and reported it to Licensed Nurse (LN) G. LN G determined the bruising was probably from the wheelchair but did not report the bruises of unknown origin to the administrator. Around 04:20 AM on 03/22/26, CNA M reported to LN G that R1 had vaginal bleeding. LN G instructed the CNA to apply antifungal powder or cream but did not assess the area. The resident remained in her room with her representative, the alleged perpetrator (AP), with the door closed. At 06:00 AM, LN G told LN H and LN I that R1 had some vaginal bleeding. At 08:00 AM, CNA O provided peri care to R1 and identified dried blood on R1's labia and reported to LN I. At 08:30 AM LN I assessed R1 and noted dried blood on the labia and vaginal area, and bruising to the right hip and leg. LN I notified LN H. Around 02:22 PM, LN H and LN I…
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.
- Actual harm · Gcited before2026-03-30 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure staff identified Resident (R) 1's signs of physical and sexual abuse, and report to the Administrator immediately and the appropriate state entities within the required time. On 03/21/22 at around 10:30-11:00 PM Certified (CNA) M and CNA N identified bruising on R1's right leg and reported it to Licensed Nurse (LN) G. LN G spoke to the resident's representative, the alleged perpetrator (AP), who offered a rationale for the injury which LN G accepted without investigation. Around 04:20 AM on 03/22/26, CNA M reported to LN G that R1 had vaginal bleeding. LN G instructed the CNA to apply topical cream but failed to assess the area. LN G did not document the bruising, the conversation with the AP or the change in condition of R1's vaginal area and failed to report bruising or vaginal bleeding to Administrative Staff A. At 06:00 AM, LN G told LN H and LN I that R1 had some vaginal bleeding and bruising. Neither LN H or LN I identified the injuries…
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.
- Actual harm · G2026-03-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to implement protective measures after injuries of unknown origin and signs of potential sexual abuse were identified to prevent further abuse. On 03/21/22 at around 10:30-11:00 PM Certified (CNA) M and CNA N identified significant bruising on R1's right leg and reported it to Licensed Nurse (LN) G. R1 was unable to state how she obtained the injuries. LN G spoke to the resident's representative, the alleged perpetrator (AP), who confirmed he did not know where the bruising came from but offered a rationale for the injury which LN G accepted without further investigation. Staff left R1 in the room with the AP. Around 04:20 AM on 03/22/26, CNA M reported to LN G that R1 had vaginal bleeding. LN G did not assess R1 but instructed the CNA to apply an antifungal to R1's peri area. After the care was completed, staff left R1 alone in the room with the AP, with the door closed. At 06:00 AM, LN G told LN H and LN I that R1 had some vaginal bleeding, but the nurses did not assess the situation at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-24 · tag F0628 — isolatedProvide 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 Based on observation, interview, and record review, the facility failed to notify the Long-Term Care Ombudsman in writing of Resident (R) 41's discharge to the community. Findings included: -The Entry Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE]. R41's 05/19/2026, Medicare 5-day MDS revealed the resident had a Brief Interview for Mental Status, (BIMS) score of 15, indicating intact cognition. It further revealed an anticipated discharge date of three or fewer months. R41's Discharge MDS, dated 05/20/2026, documented the resident discharged to the community on 05/20/2026. A Social Service Progress Note, dated 05/15/2026 at 02:37 PM, revealed Social Service Staff X spoke with the resident regarding a projected discharge date of 05/26/2026. A Social Service Progress Note, dated 05/19/2026 at 2:24 PM, revealed R41 requested to discharge from the facility on 05/20/2026. The note revealed R41's physician wrote the discharge order. A Nursing Progress Note, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to provide appropriate activity of daily living (ADL) cares for three dependent Residents (R ) 3, R24, and R9, who had long, jagged, dirty nails. Findings included:1. R3's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented R3 had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She was dependent on staff for personal hygiene. R3's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 04/16/2026, did not trigger. R3's Modification of the Quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severe cognitive impairment. She required substantial to maximal staff assistance with personal hygiene. R3's Care Plan, revised 06/23/2026, instructed staff R3 was dependent for personal hygiene cares. R3's EMR under the Task tab, from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two Residents (R)3 and R9 remained free from unnecessary medications related to blood pressure medication. Findings included: - R3's Electronic Medical Record (EMR), included the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) and hypertension (elevated blood pressure). R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. R3's Care Plan, revised 06/23/2026, instructed staff to obtain blood pressure (BP) readings, as ordered. R3's EMR under the Orders tab included the following physician's orders: Clonidine (a HTN medication), 0.1 milligrams (mg), by mouth, as needed (PRN), every day, for a systolic blood pressure (SBP- the top number of a BP reading), greater than 160, one hour after medications, for a diagnosis of hypertension, ordered 01/14/2026. Obtain BP one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which require targeted gown and glove use during high contact care) when providing direct care for Resident (R) 13 and 7 who had wounds and R1 for catheter care. Findings Included: - On 06/22/2026 at 11:27 AM, R1 rested in bed with the urinary catheter collection bag directly on the floor. The collection bag contained approximately 400 milliliters (mLs) of dark brown, tea colored urine. The door into R1's room had signage that read, This room is under Enhanced Barrier Precautions. The signage educated staff further on what to wear for Personal Protective Equipment (PPE) when in contact with wounds, urinary catheters, and infections, which included gown and gloves. On 06/22/2026 at 11:30 AM, Certified Medication Aide (CMA) L confirmed the catheter collection bag was directly on the floor and should be positioned off the floor. CMA L revealed the catheter bag would be sanitized after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-16 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 39 residents with 15 residents sampled, including 6 residents reviewed for activities of daily living (ADLS). Based on observation, interview, and record review, the facility failed to provide necessary ADL cares for four sampled resident, Resident (R)16 was not shaven, R6 had dirty clothes, R29 did not get showered, and R17 received no feeding assistance. This deficient practice placed the affected residents at risk for impaired quality of life, weight loss and poor hygiene. Findings included: - The Physician Order Sheet (POS) for R16, documented the resident had a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and chorea (movement disorder). The Annual Minimum Data Set (MDS) for R16, dated 01/20/25, documented a Brief Interview for Mental Status (BIMS) of nine indicating moderate cognitive impairment. He required substantial to maximum assistance for bathing. The Functional Abilities Care Area Assessment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 39 residents. The sample included 15 residents with one sampled for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, interview, and record review, the facility failed to address necessary dialysis assessments, care, and services on Resident (R) 143's baseline care plan. This deficient practice had the risk of adverse outcomes and dialysis complications for R143 due to uncommunicated care needs. Findings: - R143's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. The admission Minimum Data Set (MDS), was in progress. R143's Baseline Care Plan, dated 04/04/25, was reviewed on 04/14/25 at 03:48 PM. It documented R143 was a full code (desired resuscitative measures) and on skilled services with therapy. R143'sBaseline Care Plan lacked documentation that R143 received dialysis or any direction for dialysis care and services. R143's EMR under the Orders tab lacked evidence of orders related to dialysis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 39 residents, with 15 residents included in the sample. Based on observation, record review, and interview, the facility failed to complete a comprehensive care plan for one of the residents sampled, Resident (R)16, to include staff instruction for the use of foot pedals while propelling the resident in his wheelchair. Findings included: - Review of R16's electronic medical record (EMR) revealed the following diagnoses: chorea (movement disorder) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He had no impairment in functional range of motion (ROM) and was independent with his wheelchair for locomotion. The Functional Ability Care Area Assessment (CAA), dated 01/20/25, documented the resident would not have a further activity of daily living (ADL)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 39 residents, with 15 residents sampled, including two residents reviewed for quality of care. Based on record review, interview, and observation, the facility failed to ensure Resident (R) 5 had adequate care when the facility did not monitor R5's weights and notify the provider of weight fluctuations as ordered. This deficient practice placed the resident at risk for health complications. Findings included: - Review of the Electronic Medical Record (EMR) documented R5 had a pertinent diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The 11/03/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. R5's Care Plan dated 11/06/24, documented that R5 required a daily weight. The plan directed staff to notify heart failure of weight gain of three pounds overnight or five pounds in three days, increased shortness of breath, or increased swelling. R5's EMR from 02/01/25 through 04/14/25, revealed R5 gained weight on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 39 residents with 15 residents sampled including four residents reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R)16 when staff failed to have foot pedals in place when staff propelled the resident in the chair. This placed R16 at risk for avoidable accidents. Findings included: - Review of R16's electronic medical record (EMR) revealed the following diagnoses: chorea (movement disorder) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He had no impairment in functional range of motion (ROM) and was independent with his wheelchair for locomotion. The Functional Ability Care Area Assessment (CAA), dated 01/20/25, documented the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 39 residents with 15 sampled. Based on observation, interview, and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status by failing to properly follow the plan of care for Resident (R) 17. Also, the facility failed to properly assess nutritional status for R143. This deficient practice had the potential to negatively affect the residents physical well-being and nutritional status. Findings: - R17's Electronic Medical Record (EMR) revealed the following diagnoses: cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and loss of cognition. The 04/22/24 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.
Show the remaining 10 citations
- Potential for harm · D2025-04-16 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 39 residents. The sample included 15 residents with one sampled for dialysis (a procedure where impurities or wastes were removed from the blood) review. Based on observation, interview, and record review, the facility failed to provide the necessary dialysis assessment, care, and services for Resident (R) 143. This deficient practice had the risk for adverse outcomes and dialysis complications for R143. Findings: - R143's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. The admission Minimum Data Set (MDS), was in progress. R143's Baseline Care Plan, dated 04/04/25, was reviewed on 04/14/25 at 03:48 PM. It documented R143 was a full code and on skilled services with therapy. The Baseline Care Plan lacked documentation that R143 received Dialysis services or any direction for dialysis care and services. R143's EMR under the Orders tab lacked evidence of orders related to dialysis care and services. R143's EMR revealed the following: An admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 39 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure blood pressure monitoring was conducted related to the use of midodrine (a medication used to increase blood pressure) for Resident (R)143. This placed R143 at risk of complications related to abnormal blood pressure. Findings included: - Review of R143's electronic medical record (EMR) revealed a diagnosis of hypotension (low blood pressure). The 04/10/25 admission Minimum Data Set (MDS) was in progress. The 04/1/425 Baseline Care Plan dated 04/04/25 documented that midodrine (a medication used to increase blood pressure) had a Black Box Warning on it. It also gave instructions for staff to take a blood pressure before giving the medication and have the resident sitting upright when they do. It directed staff not to give the medication while the resident was laying down, or within four hours of bedtime. Review of R143's EMR revealed the following physician's order:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 39 residents. The sample included 15 residents. Based on interviews, record reviews, and observation, the facility staff failed to implement Enhanced Barrier Precautions (EBP a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) for Resident (R) 5 who had a foley catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and for R37 who received a tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) and wound care. Additionally, R7, who had an ostomy (a surgical procedure that creates an opening in the abdomen to allow waste or urine to pass out of the body) lacked EBP in place. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - During an observation on 04/14/25 at 08:30 AM, no EBP signage or precautions were noted outside any of the residents' doors in any of the hallways…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 39 residents with 15 residents sampled. Based on observation, interview, and record review, the facility failed to inspect Resident (R)6's bed frame and mattress, as part of a regular maintenance program to identify areas of possible entrapment. This placed the resident at risk for injuries. Findings included: - Review of R6's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She was dependent on staff for rolling left and right while in bed and had no limitation in range of motion (ROM). The Functional Ability Care Area Assessment (CAA), dated 12/30/24, did not trigger. The Quarterly MDS, dated 09/29/24, documented the resident had a BIMS score of one, indicating severe cognitive impairment. She had limitations in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-27 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 42 residents. Based on interview and record review, the facility failed to conduct Quality Assurance Performance Improvement (QAPI) leadership meetings with the medical director in attendance at least quarterly as required. Findings included: Review of the facility QAPI sign in sheets, revealed a lack of documentation of the medical director in attendance for the following QAPI meetings: July 2022, August 2022, September 2022, October 2022, November 2022, (no documentation of a meeting conducted December 2022 or January 2023) February 2023, May 2023, June 2023, and July 2023. Interview, on 07/26/23 at 10:20 AM, with Administrative Staff B, revealed she thought the medical director did attend meetings at least quarterly but may have been by telephone. Interview, on 07/27/23 at 02:25 PM, with Consultant Nurse GG, revealed the facility conducted monthly QAPI meetings and expected the medical director to attend at least quarterly, either in person or via phone. The QAPI Plan, effective 07/01/23, instructed staff the members of the committee included the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-27 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 42 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment in two resident shower rooms for the residents of the facility. Findings included: - During an environmental tour on 07/27/23 at 11:57 AM with Housekeeping/Maintenance Staff U and Administrative Staff A, the following areas of concern were noted: 1. The shower room on [NAME] Hall had a full bag of trash resting directly on the toilet seat. A sharps container (used to hold needles, razors and other sharp objects) rested directly on the floor underneath the sink. On 07/27/23 at 11:57 AM, Certified Nurse Aide (CNA) M stated, she had put the trash on the toilet seat until she was able to take the trash out to the dumpster. CNA M confirmed residents used the toilet seat where the trash had been placed. CNA M further stated the sharps container should not be stored on the floor, but in a cabinet in the shower room. 2. The shower room on Mockingbird Hall contained one unopened box of 100 count briefs, two unopened…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-27 · tag F0880 — failed to prevent and control infections — patternProvide 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 42 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program with the failure to ensure proper storage of glucometer and insulin pen storage for a resident in transmission-based precautions for COVID-19, to prevent the spread of infection to the residents of the facility. Findings included: - Observation, on 07/25/23 at 04:00 PM, revealed Licensed Nurse (LN) J, took Resident (R) 26's (currently in transmission-based precautions for COVID-19) glucometer (a device to measure blood glucose levels) and insulin pen, from the top drawer of the medication cart and removed them from the plastic storage bags. LN J proceeded to take the glucometer and insulin pen into his room (within transmission-based precautions) obtained the blood sugar and administered insulin with the insulin pen. Then exited the room and placed them both directly on the top surface of the medication cart. LN J proceeded to clean the resident's glucometer with an alcohol wipe and place it back into a plastic bag.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-27 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 42 residents with 15 selected for review, which included one resident reviewed for abuse. Based on observation, interview and record review, the facility failed to report one Resident (R)96 allegation of abuse to the state agency as required. Findings included: - Review of Resident (R)96's Physician Order Sheet, revealed diagnoses of malnutrition with a jejunostomy tube (surgically place directly into the small intestine to help with nutrition), absence of parts of the digestive tract, and major depressive disorder. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognition and no behaviors. The Grievance/Complaint Form, dated 01/27/23, revealed Resident (R)96, had concerns with Licensed Nurse (LN) I on 01/21/23. The resident reported that LN I rushed her and grabbed her bowl of cake and it spilled. Review of Nurse Note, dated 01/20/23 at 08:00PM, described the events that took place. The resident requested LN I to leave her room and not to come…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 reported a census of 42 residents with 15 residents sampled including five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor two Residents (R)10 and R 32 for use of antipsychotic medications (drugs used to treat psychosis-related conditions and symptoms). Findings included: - The Physician Order Sheet (POS), dated 06/27/23, documented Resident (R)10 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He received an antipsychotic medication (drugs used to treat psychosis-related conditions and symptoms) six out of the seven day look-back assessment period. The Psychotic Drug Use Care Area Assessment (CAA), dated 01/04/23, documented the resident received antipsychotic medication for a diagnosis 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.
- No harm found · C2026-06-24 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility laundry. This created the risk of impaired safety and cleanliness. Findings included: - On 06/23/2026 at 02:032 PM, laundry tour with Laundry Staff U revealed the following concerns:The soiled laundry area had an area of sheet rock that measured approximately three inches by two inches that was gouged and unable to be sanitized.The ceiling vent had peeling paint surrounding it.The floor near the sewer drains covered with metal plates had four broken floor tiles. The tiles had brown residue and debris embedded in the broken areas of the tile.The base of washing machine number one had rust that was unable to be sanitized.The base of washing machine number two had rust and missing flooring. The washing machine base had brown debris near the bottom. This area was unable to be sanitized.There were multiple broken and missing floor tiles and build-up behind washing machine number two. Interview at this time with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$21,645 in federal fines across 1 penalty.
- $21,645 — penalty dated 2026-03-30
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 AMERICARE SENIOR LIVING — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.6 | -1.6 vs chain |
| Health inspection | 2 of 5 | 3.5 | -1.5 vs chain |
| Staffing | 3 of 5 | 3.6 | -0.6 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 22 homes this chain runs (chain average 3.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| R H MONTGOMERY PROPERTIES, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2003 |
| MONTGOMERY, ANNA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 01/01/2013 |
| MONTGOMERY, RICHARD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 50% | since 01/16/2003 |
| HATLESTAD, STEVEN | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2002 |
| REIKER, JAMES | Individual | CONTRACTED MANAGING EMPLOYEE; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 01/01/2003 |
| SCHADE, KYLE | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/01/2021 |
| WINDHAM, JACLYN | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2019 |
| AMERICARE SYSTEMS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2002 |
| CROSSON, CLAY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/17/2013 |
CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $321K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175233. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-24, 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.