No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Medicalodges Great Bend

1401 Cherry Lane, Great Bend, KS 67530 · For profit - Corporation · 51 certified beds · (620) 792-2165 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citations — no harm found (F0740, F0758)2 actual-harm citations3 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)2 actual-harm citations CMS recorded as corrected before the inspection ended (past non-compliance)$52,185 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • inspectors recorded 5 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 (43) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $52,185 in federal fines (most recent 2025-12-22)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1514 State Road 96 · (620) 792-7868 · Call to confirm hours
Pharmacy
3920 10th St · (620) 792-4467 · Call to confirm hours
Grocery
Dillons1.2 mi
4107 10th St · (620) 792-3591 · Call to confirm hours
Park
McKinley St · (620) 793-4160 · Typically dawn to dusk
Place of worship
5860 Eisenhower Ave · (620) 792-6901

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 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 improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased18.0%17.9%15.4%worse
Long-stay residents who lose too much weight3.5%4.9%5.4%better
Long-stay residents with a catheter left in their bladder1.1%1.6%0.9%worse
Long-stay residents with a urinary tract infection7.2%2.9%2.0%worse
Long-stay residents with depressive symptoms0.9%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.8%4.3%3.3%worse
Long-stay residents whose ability to walk worsened7.5%16.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.2%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine97.6%95.5%95.3%typical
Long-stay residents with pressure ulcers5.4%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control33.7%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.8%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication3.8%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine69.6%73.8%79.4%worse
Short-stay residents rehospitalized after admission29.0%22.4%22.6%worse
Short-stay residents with an outpatient ER visit7.0%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.701.801.67worse
Long-stay outpatient ER visits per 1,000 resident days3.132.131.80worse

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.

46.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.5%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
46.4%U.S. median 56.6%
Met the expected recovery
0.10U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy

Met the expected recovery: 46.4% 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 28 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 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 SNF46.5%CMS range 36.5–57.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 8.3–15.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge46.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge42.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge32.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.0–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.82
RN hours/ resident / day
0.44
LPN hours/ resident / day
3.27
Aide hours/ resident / day
4.53
Total nurse hours/ resident / day
0.46
RN hoursweekends
53.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 51 beds and averages 43.5 residents a day — about 85% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.27 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 3.78 hrs/resident/day on weekends vs 4.84 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.97 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2024-07-24)
17
at the previous standard inspection (2022-07-25)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

43 citations, most serious first. The 17 most serious are shown; the remaining 26 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-04-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 38 residents, with four residents reviewed for elopements (when a resident leaves the premises or a specific safe area without authorization and/or necessary supervision). Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R) 1, who the facility identified as a high risk for elopement. On 04/05/24 at approximately 04:18 PM, R1 exited the facility's 200 hall through an unlocked door, which did not alarm. R1 walked approximately the length of a football field over cracked sidewalks, uneven grassy areas, a parking lot full of large potholes, and over several curbs before falling, between two apartment buildings, behind the facility. A community member living in the apartment building called 911 and reported R1 lying on the apartment complex lawn. At 04:45 PM, Certified Medication Aide (CMA) R saw an ambulance behind the facility and identified R1 on the ambulance…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2024-02-06 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 42 residents. The sample included three residents reviewed for therapeutic diets (a modification of a regular diet to fit the nutrition needs of a particular person and are modified for nutrients, texture, and/or food allergies or intolerances). Based on observations, record review, and interviews, the facility failed to provide the physician-ordered thickened liquids to Resident (R) 1, who had a history of dysphagia (difficulty swallowing) and aspiration (inhaling liquid or food into the lungs). On 01/07/24, Certified Nurse Aide (CNA) M served R1 thin liquids during breakfast instead of nectar thick liquids (mildly thickened liquids). Licensed Nurse (LN) G observed R1 coughing and choking afterward. LN H suctioned R1 multiple times but R1 continued to sound congested. Staff sent R1 to the emergency room (ER). R1 arrived at the hospital in obvious respiratory distress, with abnormal lung sounds, and required bilevel positive airway pressure (BiPAP-medical device which helps…

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

    Nutrition and Dietary Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Jcited before2024-01-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 46 residents with three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on record review, observation, and interview, the facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent Resident (R) 1, who was severely cognitively impaired and a high risk for elopement, from exiting the facility through the window. On 12/20/23 at 08:00 PM, Certified Nurse Aide (CNA) M assisted R1 to bed and then began the constant surveillance of R1's room from the nurse's station due to R1's high elopement risk and his multiple attempts to elope. At 09:10 PM CNA N observed R1 outside the front door, knocking over the patio furniture. The temperature outside was approximately 39 degrees Fahrenheit (F). Staff assisted R1 back into the facility and noted he had no injuries but was cool to touch. Staff returned R1 to his room and noted…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2026-05-20 · 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 failed to provide Resident (R) 1, who was a known wanderer, adequate supervision to prevent R1 from wandering down three long hallways and being pushed four to five feet in the air by another resident, R2, which resulted in an injury fall. R1 sustained a left femoral neck fracture (a serious type of hip fracture, a break in the upper part of the thigh bone just below the ball of the hip joint). Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), panic disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), and fracture of the head of the left femur (thigh bone). R1's Quarterly Minimum Data Set, dated 01/12/26, documented R1 had a Brief Interview for Mental Status score of four, which indicated…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · G2025-12-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 43 residents, with six residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure six residents, Resident (R) 1, R2, R3, R4, R5, and R6, remained free from verbal and mental abuse when Certified Nurse's Aide (CNA) M exhibited aggressive behavior toward the residents. This failure resulted in R1, R2, R3, R4, R5, and R6 experiencing verbal/mental abuse, which likely caused embarrassment, humiliation, and a potential decreased quality of life using the reasonable person concept related to their psychosocial well-being. Findings included:- CNA N's Unnotarized Witness Statement, dated 12/11/25, documented CNA N and CNA M changed R1 in his room. CNA M looked at R1 and said, Ew, you smell like [expletive]. CNA N stated she tried to change the subject, and CNA M continued to speak about how R1 smelled. CNA M said, R1 smelled like he had a turd in his mouth. CNA M stated R1 probably smelled like that because of the chicken and dumplings he had last night, but R1 ate brown dumplings. CNA N…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2022-07-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide weekly weights, failed to act on Registered Dietician (RD) recommendations, failed to monitor supplement and fortified food intake and failed to ensure staff offered fortified food and nutritional supplements to R9, who was at risk for unintended weight loss and had a significant unplanned weight loss of 10.94 percent in six months. The facility further failed to implement RD recommendations, provide and monitor nutritional supplements as ordered and consistently measure weights for R18 who was at risk for weight loss. This deficient practice placed the residents at increased risk for ongoing weight loss and related complications Findings included: - The Electronic Medical Record (EMR) for R9 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure),…

    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
  • Actual harm · G2021-01-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 14 residents with four reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to implement interventions to prevent pressure ulcers for two of four sampled residents, Resident (R) 49, whose unstageable pressure ulcer (full thickness skin, muscle loss with slough and/or eschar [dead tissue] present in the base of the pressure ulcer, preventing from seeing true depth of ulcer) on his vertebrae (an arched, hollow section through which the spinal cord passes) which originally measured 2.5 centimeters (cm) x 2.5 cm x 3.0 cm increased in size and worsened to 4 cm x 3 cm. R49 also developed a new stage two pressure ulcer (partial thickness loss of skin presenting as a shallow open area with a red/pink wound bed) below the original pressure ulcer on the residents mid vertebrae, which measured 0.5 cm x 1 cm x 0.1. R39 developed a facility acquired stage two pressure ulcer to the right buttock, which measured 0.4…

    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 before2025-12-22 · tag F0609 — failed to report abuse allegations — widespread
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 43 residents, with six residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to report suspected and observed abuse of Residents (R) 1, R2, R3, R4, R5, and R6 when Certified Nurse's Aide (CNA) M exhibited aggressive behavior toward the residents. Findings included:- CNA N's Unnotarized Witness Statement, dated 12/11/25, documented CNA N and CNA M changed R1 in his room. CNA M looked at R1 and said, Ew, you smell like [expletive]. CNA N stated she tried to change the subject, and CNA M continued to speak about how R1 smelled. CNA M said, R1 smelled like he had a turd in his mouth. CNA M stated R1 probably smelled like that because of the chicken and dumplings he had last night, but R1 ate brown dumplings. CNA N said she did not know they even made brown dumplings. CNA M laughed at CNA N and said, That was sarcasm. I said it because his mouth smells like [expletive], [expletive] dumplings. CNA N stated she later saw CNA M wheel R2 in her wheelchair to eat breakfast, as R2 yelled. CNA M told…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · F2024-07-24 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 37 residents. Based on record review and interview, the facility failed to ensure staff completed the required 12-hour in-service education for Certified Nurse Aide (CNA) N and CNA T, who were all employed by the facility for at least one year. This deficient practice placed the residents at risk of decreased quality of care. Findings included: - A review of the facility's 12-hour annual in-service documentation for five certified staff members who had been employed at the facility for at least one year revealed the following: CMA T lacked dementia care training. CNA N lacked had only completed three of the required 12 in-service hours. On 07/24/24 at 09:37 AM Administrative Nurse D reported the facility utilized an electronic education system for the required education. She confirmed the above staff did not have the required education topics and /or hours. Upon request, the facility did not provide a policy for required services. The facility failed to ensure required topics and 12-hours in-service education for CMA S and T and CNA N, which placed the…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-24 · 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 identified a census of 37 residents. The sample included 12 residents with five residents sampled for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when the facility failed to secure fully pressurized supplemental oxygen cylinders in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. The facility additionally failed to ensure interventions were put in place for 22 of Residents (R) 33's 41 falls. This deficient practice placed the residents at risk for preventable accidents, falls, and injuries. Findings included: - On 07/22/24 at 08:02 AM a walkthrough of the facility revealed an unsecured oxygen storage room. The room contained 38 fully pressurized supplemental oxygen cylinder tanks stored in floor racks. The room had a numerical keypad on the entry door. No facility staff was in the storage room area. The room's keypad door auto-locked when pulled closed. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-24 · tag F0759 — failed to keep medication error rate low — pattern
    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 had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent. This deficient practice placed Resident (R) 21 at risk for significant medication errors and resulted in a facility medication error rate of 7.69 percent (%) placing all residents who received medication at risk for medication errors. Findings included: - The Physician Order, dated 04/04/24, directed staff to administer amlodipine (blood pressure lowering medication)10 milligram (mg) daily and hold for a blood pressure less than 100/65 millimeters (mm) of Mercury (Hg) if either number is lower. The Physician Order, dated 04/04/24, directed staff to administer benazepril (blood pressure lowering medication),10 mg daily, and hold for blood pressure less than 100/65 mm/Hg if either number is lower. On 07/23/24 at 07:38 AM, observation revealed Certified Medication Aide (CMA) R obtained R21's blood pressure while he was seated in the dining room and then administered medications…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-24 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure the Consultant Pharmacist (CP) identified and notified the facility and physician of the numerous times staff administered two blood pressure medications to Resident (R) 21 when the physician order indicated the medications should have been held (not administered) in April, May, and June 2024. This deficient practice placed R21 at risk for unintended results from medications. Findings included: - R21's Electronic Medical Record (EMR) recorded a diagnosis of hypertension (HTN-elevated blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R21 required set-up assistance for meals and was dependent on staff for all other activities of daily living (ADL) and mobility. R21's Medication Care Plan, dated 07/22/24, directed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-24 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 37 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to hold Resident (R) 21's blood pressure medication per the physician ordered blood pressure parameters. This deficient practice placed R21 at risk for unnecessary medications and related complications. Findings included: - R21's Electronic Medical Record (EMR) recorded a diagnosis of hypertension (HTN-elevated blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. The MDS documented R21 required set-up assistance for meals and was dependent on staff for all other activities of daily living (ADL) and mobility. R21's Medication Care Plan, dated 07/22/24, directed staff to administer R21's medications at about the same time each day and check the blood pressure before giving the medications. The care plan…

    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 · D2024-02-06 · 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 identified a census of 42 residents. The sample included three residents with one reviewed for medications. Based on observations, record review, and interview, the facility failed to accurately transcribe and administer antibiotic (medications used to treat bacterial infections) orders for Resident (R) 1 upon her return from the emergency room (ER). This deficient practice placed R1 at risk for ineffective treatment for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) and unwarranted physical complications. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), personal history of transient ischemic attacks (TIA- temporary episode of inadequate blood supply to the brain), dysphagia, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-30 · tag F0880 — failed to prevent and control infections — pattern
    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 identified a census of 44 residents. Based on observations, record review, and interviews, the facility failed to ensure oxygen tubing was stored properly, failed to ensure adequate hand hygiene, failed to prevent cross-contamination with sit-to-stand (mechanical lift that helps patient rise from a seated to a standing position) lift usage, failed to prevent cross-contamination with glucometer (device used to obtain a blood sugar level), and failed to ensure proper usage of personal protective equipment (PPE- gowns, face shields and/or eye glasses/goggles, and gloves). This deficient practice had the risk to spread illness and infection to all residents. Findings included: - On 08/30/23 at 09:52 AM, Resident (R) 1's oxygen tubing was coiled up and laid on her concentrator, not stored in a bag. On 08/30/23 at 09:58 AM, Certified Nurse Aide (CNA) M wore gloves and transported a red biohazard bag to the soiled utility room. She exited the soiled utility room within seconds, no longer wearing gloves. CNA M pushed a sit-to-stand lift into the clean storage room, exited…

    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 · E2022-07-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review and interview the facility staff failed to handle beverages appropriately and clean the plate carts before placing clean dishes on them. This deficient practice placed the 44 residents of the facility at risk for food borne illness. Findings included: - On 07/19/22 at 12:40 PM, observation revealed Certified Nurse Aide (CNA) P served room trays on the 300 hall. She removed the lids on the beverages, then held the glasses by the top rim when taking them into five residents' rooms. On 07/20/22 at 11:45 AM, observation just before lunch revealed the cart for clean dishes, trays, and lids had dried food crumbs on each shelf with the clean dishes. On 07/21/22 at 11:55 AM, observation in the dining room revealed CNA O handled three residents' beverages by the top rim while serving and Certified Medication Aide (CMA) S handled two residents' beverages by the top rim while administering medications. On 07/21/22 at 1203 PM, observation just before lunch revealed the cart for clean…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-25 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 44 residents. The sample included 16 residents with five sampled for immunizations. Based on record review and interview, the facility failed to provide documentation for five sampled residents influenza (a highly contagious viral infection of the respiratory passages causing fever, severe aching, inflammation of the nose and throat, often occurring in epidemics) vaccinations, Resident (R)27, R6, R28, R19, and R24. This placed the residents at increased risk of illness. Findings included: - On 07/21/22 at 09:30 AM, review of R27, R6, R28, R19, and R24's medical records lacked documentation staff administered each resident the annual influenza vaccination. On 07/21/22 at 01:30 PM, Administrative Nurse D verified the facility lacked documentation each resident had received, or staff had administered the annual influenza vaccination to the resident. Administrative Nurse D verified she had started at the facility December 2021 and the facility lacked documentation the residents received their 2021 annual influenza vaccines. The facility's Resident…

    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
Show the remaining 26 citations
  • Potential for harm · E2022-07-25 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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

    The facility had a census of 44 residents. The sample included 16 residents. Based on observation, interview, and record review the facility failed to provide a clean, comfortable, safe environment by not ensuring the kitchen floor tiles remained intact and failed to ensure the ice machine drainage system had a two inch air gap in the line. This deficient practice placed residents at increased risk for illness. Findings included: - On 07/19/22 at 08:30 AM, observation revealed nine cracked floor tiles, 12 by 12 inch, with cracks and missing pieces in the facility kitchen. On 07/20/22 at 11:45 AM, observation revealed the ice machine drainpipe rested on floor and drain hole. On 07/25/22 at 10:02 am, Dietary Staff BB verified the observation of the broken floor tiles and the lack of air space in the drainage system. The Monthly Cleaning Schedule, dated May through December 2022, included the task of cleaning the ice machine, and was initialed May, June and July. Upon request the facility did not provide a policy for the ice machine. The facility failed to provide a clean, comfortable,…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review and interview, the facility failed to identify and report Resident (R)24's missing fentanyl (narcotic medication for pain) patchs to the State Agency (SA) as an allegation of misappropriation. This placed the resident at risk for ongoing abuse and/or misappropriation. Findings included: - R24's Physician Order Sheet, dated 05/25/22, revealed diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion.) R24's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R24 had severely impaired cognition. The MDS recorded she required extensive two staff assistance with bed mobility, dressing, toileting and personal hygiene. The MDS documented the resident received an opioid (a class of pain-relieving medication including…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-25 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to investigate Resident (R) 24's missing fentanyl (narcotic) patches. This placed the resident at risk for ineffective pain relief and unidentified misappropriation. Findings included: - R24's Physician Order Sheet, dated 05/25/22, revealed diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion.) R24's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R24 had severely impaired cognition. The MDS recorded she required extensive two staff assistance with bed mobility, dressing, toileting and personal hygiene. The MDS documented the resident received an opioid (a class of pain-relieving medication including fentanyl) pain medication seven days a week. The Pain Care Plan, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-25 · tag F0655 — isolated
    Create 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed provide a baseline care plan within forty-eight (48) hours of admission for Resident (R) 37 which placed the resident at risk of unmet care needs. Findings included: -The Medical Diagnosis section within R37's Electronic Medical Records (EMR) included diagnoses of failure to thrive, retention of urine, intracerebral hemorrhage (condition in which a ruptured blood vessel causes bleeding inside the brain), chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) , chronic kidney disease, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) heart failure, and malignant neoplasm (cancer tumor) of upper lobe left bronchus or lung. The admission Comprehensive Minimum Data Set (MDS), 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive plan of care for Resident (R)37 which placed the resident for unmet care needs. Findings included: - The Medical Diagnosis section within R37's Electronic Medical Records (EMR) included diagnoses of failure to thrive, retention of urine, intracerebral hemorrhage (condition in which a ruptured blood vessel causes bleeding inside the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) , chronic kidney disease, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and heart failure, malignant neoplasm (cancer tumor) of upper lobe left bronchus or lung. The admission Comprehensive Minimum Data Set (MDS), dated [DATE], documented R37 had moderately impaired…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents, with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent weight loss for one sampled resident, Resident (R) 9, who was at risk for unintended weight loss and had a significant weight loss of 10.94% in six months. This placed the resident at increased risk for ongoing weight loss and related complications. Findings included: - The Electronic Medical Record (EMR) for R9 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), adjustment disorder with anxiety (a stress related condition), hypertension (high blood pressure), and pain (an unpleasant sensory and emotional experience, associated with or expressed in terms of actual or potential tissue damage). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had severely impaired cognition, inattention, and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents, with 11 reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment and failed to implement resident centered interventions for one sampled resident, Resident (R) 3, who had multiple falls. This placed the resident at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues), unsteadiness on feet, diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to insulin), chronic systolic heart failure (the left ventricle of your heart, which pumps most of the blood, has become weak), hypertension (high blood pressure). The Medicare-5 Day Minimum Data Set (MDS), dated [DATE], documented R3 had severely impaired cognition and required extensive assistance of two staff for bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents, with one resident reviewed for bowel and bladder function. The facility failed to provide Resident (R) 37 with assessment and interventions to prevent further bladder incontinence. This placed R37 at risk for functional decline and impaired dignity. Findings included: -The Medical Diagnosis section within R37's Electronic Medical Records (EMR) included diagnoses of failure to thrive, retention of urine, intracerebral hemorrhage (condition in which a ruptured blood vessel causes bleeding inside the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) , chronic kidney disease, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) heart failure, and malignant neoplasm (cancer tumor) of upper lobe left bronchus or lung. The admission Comprehensive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-25 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents, with four reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one sampled resident, Resident (R) 14, who stated he wanted to kill himself twice within a three-month period. This placed the resident at risk for further decline of his emotional and mental-wellbeing. Findings included: - The Electronic Medical Record (EMR) documented R14 had diagnoses of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), panic disorder (a disorder in which debilitating anxiety and fear arise frequently and without reasonable cause), and depression (abnormal emotional state…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-25 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of one sampled resident, Resident R14, who stated he wanted to kill himself twice within a three-month period. This placed the resident at risk for further decline of his emotional and mental-wellbeing. - The Electronic Medical Record (EMR) documented R14 had diagnoses of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), panic disorder (a disorder in which debilitating anxiety and fear arise frequently and without reasonable cause), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-25 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report multiple episodes of blood pressures outside of physician ordered parameter for Resident (R) 14. This placed R14 at risk for physical decline and complications related to low blood pressure. Findings included: - The Electronic Medical Record (EMR) documented R14 had diagnoses of hypertension (high blood pressure), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), panic disorder (a disorder in which debilitating anxiety and fear arise frequently and without reasonable cause), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold amlodipine (a medication for high blood pressure) and olmesartan medoxomil-hctz (a medication for high blood pressure) when systolic blood pressures were out of parameter for one of five sampled residents, Resident (R) 14. This placed R14 at risk for physical decline and complications related to low blood pressure. Findings included: - The Electronic Medical Record (EMR) documented R14 had diagnoses of hypertension (high blood pressure), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), panic disorder (a disorder in which debilitating anxiety and fear arise frequently and without reasonable cause), and depression (abnormal…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 resident. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 14's PRN (as needed) diazepam (a sedative used to treat anxiety). and failed to ensure an appropriate diagnosis for R17's Seroquel and Zyprexa (antipsychotic medication). Findings included: - The Electronic Medical Record (EMR) documented R14 had diagnoses of hypertension (high blood pressure), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), panic disorder (a disorder in which debilitating anxiety and fear arise frequently and without reasonable cause), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness. The Significant Change…

    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 · D2022-07-25 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 16 residents with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R24. This placed R24 at risk for inappropriate end of life cares. Findings included: - R24's Physician Order Sheet, dated 05/25/22, revealed diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion.) R24's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R24 had severely impaired cognition. The 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-01-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 49 residents. Based on observation, interview, and record review, the facility failed to perform appropriate infection control procedures when providing care for a newly admitted resident in quarantine/isolation for potential Covid 19 infection. Findings included: - Resident (R) 101's medical record documented the facility admitted the resident 01/12/21, and staff placed the resident in droplet precautions for Covid 19 (a mild to severe respiratory illness caused by a new strain of coronavirus, characterized by fever, cough, shortness of breath), which required 14 days of precautions. On 01/21/21 at 09:14 AM, observation revealed Licensed Nurse (LN) G, who wore an isolation gown, face mask, and goggles entered quarantined R101's room in the Special Care Unit (SCU), stood close to her bed and obtained a blood pressure with a wrist cuff. Continued observation revealed LN G did not remove the isolation gown, face mask, and goggles before leaving the isolation room and continued to wear the potentially contaminated gown, goggles and face mask when leaning…

    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 · D2021-01-27 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 14 residents with one reviewed for advanced directives. Based on record review and interview, the facility failed to provide advance directive signed by the physician for one sampled resident, Resident (R) 100. Findings included: - The Physician Order Sheet (POS), dated [DATE], documented diagnoses of type 2 diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), mild cognitive impairment (the stage between the expected cognitive decline of normal aging and the more serious decline of dementia), other signs and symptoms involving cognitive function and awareness, dementia (progressive mental disorder characterized by failing memory and confusion), and major depressive disorder (major mood disorder). R100's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score 0, indicating severe cognitive deficit. The MDS 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-01-27 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 14 residents of which two were reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to notify the ombudsman when Resident (R) 49 transferred to the hospital and remained in the hospital. Findings included: - R49's Discharge Minimum Data Set (MDS), dated [DATE], documented the resident had an unplanned discharge to an acute hospital. The 12/05/20 at 02:54 PM Nurse's Note, documented the nurse heard the resident yelling, help me from down the 100 hallway. The nurse ran down to see who it was and what happened. When the nurse got to the resident's room, he was laying on the floor in front of his closet. His four wheeled walker was in front of his bathroom door but his television (TV) stand was pulled almost a foot away from the wall on the side closest to the bathroom. The resident was not wearing shoes and his pants hung loosely on him, his feet were facing toward the hallway and his head was toward 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 · Dcited before2021-01-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to update Resident (R) 47's care plan to include hospice and R49's care plan to prevent pressure ulcers. Findings included: - R47's Significant Change Minimum Data Set (MDS), dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented the resident required extensive staff assistance with bed mobility, transfer, locomotion on and off unit, dressing, and toilet use, limited staff assistance with personal hygiene, and supervision with eating. The MDS documented the resident received hospice services. The Activities of Daily Living (ADL) Care Plan, dated 08/24/20, documented the resident required extensive staff assist with bed mobility, dressing, transfers, toilet use, and set up staff assistance with eating. The care plan instructed staff to encourage the resident to participate 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 14 residents with six reviewed for accidents. Based on observation, interview, and record review, the facility failed to implement interventions to prevent falls for one of six residents, Resident (R) 34, including a Three Day Bladder Assessment designated to prevent further falls. Findings included: - R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. The resident required limited staff assistance for walking and eating, extensive staff assistance of one for toileting, transfers, and extensive staff assistance of two for dressing, and bed mobility. The MDS documented the resident required assistance to regain her balance, used a wheelchair for mobility, and had non-injury fall since the previous MDS. The Annual MDS, dated 11/20/20, documented the same as the 09/05/20 assessment except; the resident had a BIMS score of zero,…

    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 before2021-01-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 14 residents with three reviewed for urinary catheter or Urinary Tract Infection (UTI). Based on observation, interview, and record review, the facility failed to provide interventions to prevent a UTI for one of three residents sampled, Resident (R) 22. Findings included: - R22's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS documented the resident was independent for all Activities of Daily Living (ADLs) and, had occasional urinary incontinence. The Quarterly MDS, dated 11/04/20, documented a Brief Interview for Mental Status (BIMS) of 11, which indicated moderately impaired cognition, independent for all Activities of Daily Living (ADLs), had a urinary catheter (tubing inserted into the bladder to drain the urine into a collection bag), and received antibiotics six days of the lookback period. The Urinary Care Plan, dated 01/14/21,…

    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 before2021-01-27 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 14 residents with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure the consultant pharmacist identified irregularities (blood sugar parameters for Resident (R) 48) and the facility failed to act upon the consultant pharmacist's recommendations (need for quarterly DISCUS [Dyskinesia Identification System Condensed User Scale] for R42). Findings included: - R48's admission Minimum Data Set (MDS), dated [DATE] , documented Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. The MDS documented the resident was independent with eating, required supervision with transfers, bed mobility, locomotion, extensive staff assistance with dressing and toileting. The resident received insulin seven days of the lookback period. The Medication Care Plan, dated 12/15/20, directed staff to monitor labs as ordered by my physician and to provide my…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-01-27 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sampled included 14 residents with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to obtain physician orders for blood sugar parameters for Resident (R) 48 who received insulin (hormone which promotes the absorption of glucose from the blood). Findings include: - R48's admission Minimum Data Set (MDS), dated [DATE], documented Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. The MDS documented the resident was independent with eating, required supervision with transfers, bed mobility, locomotion, extensive staff assistance with dressing and toileting. The resident received insulin seven days of the lookback period. The Medication Care Plan, dated 12/15/20, directed staff to monitor labs as ordered by my physician and provide my medications as ordered. If my health status changed have my physician review my medications for potential change. Please…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-01-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 14 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to complete quarterly DISCUS (Dyskinesia Identification System Condensed User Scale) to assess for side effects for one of five sampled residents, Resident (R) 42. Findings included: - R42's Physician Order Sheet, dated 12/08/20, documented the resident had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia with behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder), and pseudobulbar affect (a condition characterized by an involuntary and uncontrollable reaction of laughter or crying that is disproportionate). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident received antipsychotic medication on a daily basis. The Psychotropic Drug…

    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 · D2021-01-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents with 2 medication carts. Based on observation, interview, and record review, the facility failed to label opened insulin (hormone which allows cells throughout the body to uptake glucose) pens with the opened date for two of three insulin dependent residents, Residents (R) 101 and R44, and to dispose of an outdated insulin pen for one of three insulin dependent residents, R5 from 1 of 2 medication carts. Findings included: - On [DATE] at 08:09 AM, Licensed Nurse (LN) G opened the 300-400 hall nurse's medication cart and checked the opened insulin pens and observation revealed the following: One Basaglar insulin pen without an opened date for R101, expired 28 days after opening. One Novolog insulin 70/30 pen without an opened date for R44, expired 14 days after opening. One Novolog flex pen without an opened date for R44, expired 28 days after opening. One Novolog flex pen, dated [DATE], for R5, expired 28 days after opening. On [DATE] at 08:10 AM, LN G verified R5's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-01-27 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 49 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to ensure one unsampled resident, Resident (R) 8, received assistance with her meal in a timely manner before the food became unpalatable at 80 degrees Fahrenheit (F). Findings included: - R8's Nutrition Care Plan, dated 01/17/19, directed staff to provide assistance with eating. The care plan documented the resident required staff to put the bite on the fork, then cue her to take it to her mouth. She will do this and at times will continue to feed self without cue. If she starts to forget what to do, again put the food on her fork and cue her to take a bite. She needs multiple cues at meal times. 01/20/21 at 12:23 PM, observation revealed staff delivered a meal to R8. The very confused resident sat in her chair with the meal beside her, but she did not attempt to eat. At 12:39 PM the activity director assisted the resident to eat. On 01/21/21 at 12:17 PM, observation revealed staff delivered a meal to R8 and continued to deliver meals…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2021-01-27 · tag F0575 — widespread
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility had a census of 49 residents. Based on observation and interview, the facility failed to post the required Kansas Department for Aging and Disability Services (KDADS) complaint hotline telephone number. Findings included: - On 01/27/21 at 02:34 PM, observation in the common areas of the facility revealed no posting of the Kansas Department for Aging and Disability Services (KDADS) complaint hotline telephone number. On 01/27/21 at 02:22 PM, the resident council member Resident (R) 19 stated she did not know where to find the KDADS Abuse, Neglect, and Exploitation, hotline number. On 01/27/21 at 02:35 PM, Administrative Staff A verified the KDADS hotline was not posted. The facility failed to post access information for the KDADS hotline, placing the residents at risk for being unable to report incidents including abuse, neglect, and exploitation.

    Resident Rights 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

$52,185 in federal fines across 4 penalties.

  • $10,358 — penalty dated 2025-12-22
  • $16,149 — penalty dated 2025-04-21
  • $15,642 — penalty dated 2024-02-06
  • $10,036 — penalty dated 2024-01-10

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 2 of 52.7-0.7 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 4 of 53.6+0.4 vs chain
Quality measures 2 of 52.8-0.8 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 INTEREST100%since 04/19/1976
CRAFT, ALISHAIndividualW-2 MANAGING EMPLOYEEsince 10/01/2018
BUTLER, RICHARDIndividualCORPORATE DIRECTORsince 07/01/2003
COX, GARENIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 02/26/1998
DOLL, GAYLEIndividualCORPORATE DIRECTORsince 03/10/2005
HINES, SCOTTIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/20/2009
LAGER, SHANNONIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/23/2018
MARSHALL, CAROLIndividualCORPORATE DIRECTORsince 07/27/2006
OTT, RONIndividualCORPORATE DIRECTORsince 09/15/2006
CARDENAS, STACIIndividualCORPORATE OFFICERsince 07/01/2014
COOVER, TERESAIndividualCORPORATE OFFICERsince 09/21/2017
LANTZ, KATHLEENIndividualCORPORATE OFFICERsince 11/01/2013
MCBRIDE, TRAVISIndividualCORPORATE OFFICERsince 11/01/2013
ROHLING MCCORD, CATHERINEIndividualCORPORATE OFFICERsince 06/09/2000
SMITH, PAMELAIndividualCORPORATE OFFICERsince 07/01/2014

CMS files one row per role, so the 18 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$4.3M
Net patient revenuemost recent cost report
-12.1%
Operating marginrevenue minus expenses
$215K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 11%Other / private 89%

This home reported $215K 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

$304per resident / day
operating cost
$9,254per month
≈ monthly operating cost
$272per 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 175522. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-24, 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.

What to do next