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

Halstead Health And Rehabilitation Center

915 McNair Street, Halstead, KS 67056 · For profit - Corporation · 60 certified beds · (316) 835-3535 Medicare & Medicaid certified

Call the home — (316) 835-3535 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations$16,355 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,355 in federal fines (most recent 2026-05-19)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • about 17% of its spending goes to commonly-owned related companies

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
501 N Commercial Ave · (316) 655-3787 · Call to confirm hours
Pharmacy
Walmart8.9 mi
1701 S Kansas Rd · (316) 284-2333 · Call to confirm hours
Grocery
145 Main St · (316) 835-2251 · Call to confirm hours
Park
327 Locust St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 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 rating4★
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 increased9.6%17.9%15.4%better
Long-stay residents who lose too much weight5.0%4.9%5.4%typical
Long-stay residents with a catheter left in their bladder0.7%1.6%0.9%better
Long-stay residents with a urinary tract infection0.7%2.9%2.0%better
Long-stay residents with depressive symptoms0.0%6.5%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.9%4.3%3.3%better
Long-stay residents whose ability to walk worsened8.9%16.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication31.1%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers5.2%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control16.3%22.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.9%18.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

52.7% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.7%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF52.7%CMS range 38.5–61.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.6–16.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 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

0.89
RN hours/ resident / day
0.27
LPN hours/ resident / day
2.32
Aide hours/ resident / day
3.49
Total nurse hours/ resident / day
0.39
RN hoursweekends
38.5%
Total nursing turnover
12.5%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 36.7 residents a day — about 61% occupied, or roughly 23 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 is below 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 3.07 hrs/resident/day on weekends vs 3.65 on weekdays — 16% thinner on weekends. RN hours go from 1.10 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2026-04-15)
14
at the previous standard inspection (2024-05-20)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2024-05-20 · 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 identified a census of 41 residents with 12 residents sampled, which included one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to assess and provide treatment to prevent a pressure injury for Resident (R)13. On 05/08/24, staff observed two intact blisters on R13's coccyx (area at the base of the spine). Staff failed to notify the provider until 05/14/24, six days later, when the two areas developed into stage two (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers. This placed the resident at risk to worsen her pressure ulcers and delayed healing. Findings included: - Resident (R) 13's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose,…

    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 · Gcited before2024-05-20 · 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 census totaled 41 residents with 12 residents included in the sample, including one resident reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure a safe environment for one cognitively impaired Resident (R)35, when staff failed to check the temperature of a bowl of soup before serving it to the resident. Resident (R35) suffered burns, that developed blisters, on two fingers of his right hand when he placed them in the hot bowl of soup during mealtime. Findings included: - R35's Electronic Medical Record (EMR) revealed the following diagnoses: Alzheimer's disease with early onset (progressive mental deterioration characterized by confusion and memory failure), vascular dementia (progressive mental disorder characterized by failing memory, confusion) with psychosis (any major mental disorder characterized by a gross impairment in reality perception), agitation (feeling of aggravation or restlessness brought on by a provocation or a medical…

    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 before2026-04-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation in the facility's one kitchen to prevent the spread of food borne illness to the residents of the facility. Findings included:- Initial tour of the kitchen on 04/13/2026 at 8:00 AM with Dietary Manager CC revealed the following areas of concern:Various containers and plates were not inverted on the drying rack in the kitchen which exposed the eating surfaces to potential contaminants.Two packages of cheese slices wrapped in plastic and one plastic bag with ham slices in the kitchen cooler with the dates 04/09 and 04/12, absent of year.One container with barbeque sauce dated 03/26; one large container of picante sauce dated 02/24; one large container of relish dated 03/24; one large container of Kens Ranch salad dressing dated 04/08/25 with no expiration date; one large container of mayonnaise dated 03/10; one large container of Reliance Italian dressing dated 03/03; one container of green olives dated 06/19; one large container with maraschino…

    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 · Ecited before2026-04-15 · 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

    Based on observation and record review the facility failed to maintain an effective infection control program related to Enhanced Barrier Precaution (EBP- infection control interventions designed to reduce transmission of resistant organism which employ targeted gown and gloves use during high contact care) during wound care. Additionally, staff failed to keep laundry cart covered during delivery of clean clothing. Findings included:- An observation of tracheostomy care for Resident (R) 2 on 04/14/26 at 07:50 AM, revealed Licensed Nurse (LN) H performed hand hygiene, donned gloves, and wore a mask, LN H did not don a gown prior to providing cares and changing gloves before placing clean four by four gauze or the tracheostomy cannula (a tube to maintain a patient's airway for breathing). An observation on 04/14/26 at 11:35 AM, during the delivery of resident's personal items, revealed Housekeeping/Laundry Staff U placed the covered cart in hall 100, then took the items off the cart and carried the items over her shoulder to hall 200 without the cart, uncovered. During an observation…

    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 · Dcited before2026-04-15 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately complete the [NAME] Data Set for Resident (R) 13. Findings included:- R13's Electronic Medical Record (EMR) documented diagnoses hemiparesis/hemiplegia (weakness and paralysis on one side of the body), chronic osteomyelitis (local or generalized infection of the bone and bone marrow), and intervertebral disc disorder (occurs when the discs between vertebrae are damaged or degenerate, leading to compression or irritation of nearby nerve roots.) with radiculopathy (pain, tingling, or weakness radiates along the affected nerve, often down the legs). R13's 03/24/26 Quarterly Minimum Data Set (MDS) documented a BIMS of 15. The MDS noted R13 required supervision for walking 10 feet and required partial assistance for walking 50 feet. The MDS incorrectly documented R13 had no falls since the previous MDS assessment. R13's Care Plan, dated 01/16/25, documented R13 continued to do things independently even when he had been educated…

    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 before2026-04-15 · 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

    Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when staff failed to provide the necessary foot pedals when assisting propelling Resident (R)3 in a wheelchair. Findings included: - R3's Electronic Medical Records (EMR) documented diagnoses that included severe morbid obesity, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and noncompliance. R3's 12/24/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R3 had one fall with minor injury since the previous assessment. R3's 12/24/25 Falls Care Area Assessment (CAA) documented R3 had falls in the previous three months and he was at risk for falls. R3's 3/10/26 Quarterly MDS documented a BIMS score of 15. The MDS documented R3 had one noninjury fall…

    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 before2026-04-15 · 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 Based on observation, interview, and record review, the facility failed to provide appropriate care and treatment of a suprapubic catheter (tube surgically inserted through the abdominal wall into the bladder to drain urine) when staff anchored the suprapubic tubing to Resident (R)6's leg instead of his abdomen as indicated by current standards of practice to prevent pulling or dislodgement. Findings included: - R6's Electronic Medical Record (EMR) from the Diagnosis tab documented Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), chronic kidney disease-stage three (CKD), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), obstructive uropathy (a structural or functional blockage in the urinary tract that prevents urine from flowing freely, causing it to back up and damage the kidneys), and retention of urine (the inability to fully or…

    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 · D2026-04-15 · 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

    Based on observation, interview, and record review, the facility failed to ensure nutritional maintenance for Resident (R) 27. The facility failed to follow the registered dietitian's recommendations for providing facility meal shakes to R27 three times daily and R27 had a 3.16% weight loss in 14 days. Findings included:- The Electronic Health Records (EHR) for R27 included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), chronic pain, unspecified intellectual disabilities, and major depressive disorder. R27's Quarterly Minimum Data Set (MDS), dated 03/17/26, documented a Brief Interview for Mental Status (BIMS) of three, which indicated severe cognitive impairment. The MDS also documented R27 used a wheelchair for mobility and required set-up or clean-up assistance for eating. The MDS documented R27 had a listed weight of 123 pounds (lbs.) and had coughing or choking during meals or swallowing medication. The MDS documented R27 had no weight loss or gain. R27's Care Plan, dated 01/03/23, documented a focus on his nutrition.…

    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 before2026-04-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure emergency equipment, that included an Ambu bag (a handheld, manual, self-inflating resuscitator used to deliver positive pressure ventilation to patients with inadequate or no breathing) was readily available in the event of an accidental extubation (removal of a medical tube) of Resident (R)2's tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) cannula. Findings included:- The Electronic Health Records (EHR) for R2 included diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations), encounter for attention to tracheostomy (care, cleaning, and maintenance of the artificial opening in the throat used for breathing), obesity (excessive body fat), dysphagia (swallowing difficulty), malignant neoplasm of nasopharynx (an uncommon, often aggressive cancer starting in the upper throat behind the nose), and chronic respiratory failure with hypoxia a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 41 residents with one main kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and under sanitary conditions to the residents of the facility to prevent the potential for food borne bacteria by the staff's failure to date and reseal open food items in the refrigerators and freezer, and the failure to clean the thermometer between food items while taking food temperatures prior to serving. This had the potential to affect all 41 of the residents' receiving meals from the main kitchen. Findings included: - On 05/15/24 at 08:30 AM, initial tour with dietary staff H, the kitchen revealed the following areas of concern: In the reach-in refrigerator revealed two bags containing onions that had been partially used and neither were dated. A large block of cheese slices that was opened and lacked a date. A large package of opened, lunch meat and lacked a date. In addition, the freezer contained an an open tub of ice cream, undated and without a lid. The walk-in freezer had a large bag of hamburger patties…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-20 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - Resident (R)42's Electronic Health Record (EHR) revealed diagnoses of obstructive sleep apnea (disorder of sleep characterized by periods without respirations), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R42 was independent with ADLs (activities of daily living such as walking, grooming, toileting, dressing and eating). The 03/14/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R42 was independent in ADLs, except required set-up to complete showers. The Physician's Order dated 04/11/24, included the resident to have CPAP (continuous positive airway pressure - a ventilation device that blows a gentle stream of air into the nose to keep airway open during…

    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 · Fcited before2024-05-20 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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 census totaled 41 residents. Based on observation, interview, and record review the facility failed to provide a sanitary environment by the failure to have lids on the linen cans in the shower rooms, failure to have a lid on the biohazard container in the soiled utility room and failure to maintain appropriate flooring in the laundry area. These deficient practices had the potential to be an unsanitary environment which would affect all residents in the facility. Findings included: - On 05/21/24 at 11:55 AM, Maintenance Director F, identified one soiled utility room in the facility during environmental tour and four shower rooms: 1. On the 100-hall, the soiled linen can in the shower room lacked a lid or cover. 2. On the 200-hall, the soiled linen can in the shower room lacked a lid or cover. 3. On the 300-hall, the soiled linen can in the shower room lacked a lid or cover. 4. On the 400-hall, the soiled linen can in the shower room lacked a lid or cover. 5. In the soiled utility room, the biohazard box lacked a lid or cover. 6. In the laundry room, a large crack 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · E2024-05-20 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable and homelike environment to the residents that resided in the facility. Findings included: - On 05/21/24 at 09:19 AM, physical environmental tour with Maintenance Director F revealed the following areas of concerns: 1. On the floor transition from the main area to the 200 hall, an area of frayed carpeting. 2. On the floor transition from the main area to the 300 hall, an area of frayed carpeting. 3. On the floor in the 200 hall, one floor sewer cleanout cap was loose and was able to be lifted easily. 4. On the divider wall inside the 400 hall shower, two tiles along the base and corner were broken with jagged exposed edges. 5. On the transition between the floor to the wall in the 200 hall shower, an unknown black substance was between the tiles. On 05/21/24 at 09:40 AM, Maintenance Director F confirmed the above findings. On 05/21/24 at 09:50 AM, Administrative Staff A confirmed the above findings and stated they would be immediately…

    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 · E2024-05-20 · tag F0656 — failed to write and follow a full care plan — pattern
    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 41 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for Resident (R)13's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The facility further failed to develop a care plan for R19's care and maintenance of respiratory equipment. The facility further failed to develop a care plan for R42's dysphagia (swallowing difficulty). The facility further failed to develop a care plans' for R26's monitoring of behaviors for psychotropic (alters mood or thought) medications. This deficient practice placed the residents at risk for inadequate care and services. Findings included: - Resident (R)42's Electronic Health Record (EHR) revealed diagnoses of dysphagia (swallowing difficulty), schizophrenia (mental disorder characterized by gross distortion of reality,…

    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 · Ecited before2024-05-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R26's signed physician orders dated 05/15/24 revealed the following diagnoses that included ,anxiety disorder, type 2 diabetes mellitus with diabetic chronic kidney disease (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), sleep apnea (disorder of sleep characterized by periods without respirations), encounter for attention to tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted), dysphagia (swallowing difficulty), malignant neoplasm of nasopharynx (a rare type of cancer that occurs in the nasopharynx, behind your nose and above your throat.), and chronic respiratory failure with hypoxia (inadequate supply of oxygen). R26's Significant Change in Status Minimum Data Set (MDS) dated 10/21/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent on staff for all cares except eating which required setup and supervision. R 26 received as…

    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 · E2024-05-20 · tag F0756 — failed to review each resident's drug regimen — pattern
    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 41 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to reply in a timely manner and act upon the Consultant Pharmacist of Medication Regimen Review (MMR) and Gradual Dose Reduction (GDR) recommendations for Residents (R) 8, R24, R26, R33 and R 35 medication regimen review. This deficient practice placed these residents at risk for receiving unnecessary medications. Findings included: - Resident (R)33's Electronic Health Record (EHR) revealed diagnoses of mixed hyperlipemia (condition of elevated blood lipid levels), chronic kidney disease and benign paroxysmal vertigo (sensation of spinning, dizziness). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R33 had no depression. R33 ADL's documented independent (activities of daily living such as walking, grooming,…

    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 · D2024-05-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)13 received care in a dignified manner during incontinent care when the window blind was left open. This deficient practice placed the resident at risk for decreased psychosocial well-being. Findings included: - Resident (R) 13's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying) and other idiopathic peripheral autonomic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R13…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-20 · 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 reported a census of 41 residents, with 12 residents sampled, including one resident sampled for advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed Resident (R)16 by having the guardian sign a completed Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest). Findings included: - Resident (R) 16's Electronic Health Record (EHR) revealed diagnoses of unspecified dementia (progressive mental disorder characterized by failing memory, confusion), unspecified intellectual disabilities and chronic atrial fibrillation (rapid, irregular heartbeat). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) not assessed, completed staff interview documented short and long term memory problem. R16 required partial to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-20 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for two sampled residents, Resident (R)19 related to oxygen use, and R9 related to completion of sections C and D of the Minimum Data Set (MDS). This placed the residents at risk for uncommunicated care needs. Findings include: - The 02/27/23 Electronic Health Records (EHR) documented R19 had the following diagnoses that included pulmonary fibrosis (a disease of the lung that causes scarring and stiffening of the tissues over time which causes increased work of breathing) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest). The 10/17/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R19 was independent…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-20 · 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

    The facility reported a census of 41 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the person-centered care plan for one resident, Resident (R)30 related to use, care and maintenance of nebulizer equipment. This deficient practice had the potential to place the resident at risk for not receiving appropriate cares and treatments. Findings included: - The Electronic Health Records (EHR) documented R30 had the following diagnoses that included congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest) with hypoxia (inadequate supply of oxygen in the blood). The 09/19/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R30 was dependent on staff assistance for all cares except eating which was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)13 received care for removal of facial hair. This deficient practice placed the resident at risk for decreased psychosocial well-being. Findings included: - Resident (R) 13's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and other idiopathic peripheral autonomic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R13 required maximal to total assistance with ADL's (activities of daily living such as bed mobility, toileting, dressing, and bathing). The Quarterly MDS dated 04/23/24, documented a BIMS of 14. R13 required total…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-10-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 36 residents. Based on observation and interview, the facility failed to maintain food preparation equipment in a clean manner and failed to ensure a two-inch air gap between the ice machine drainage pipes and floor drain to prevent the spread of food borne illness. Findings included: - Observation on 10/05/22 at 02:25 PM, during the environmental tour of the kitchen revealed the stand-alone oven contained six baking racks covered with a black hard substance and the interior of the oven, that included the doors, contained splatters of black baked on substances over the entire surfaces. Interview, on 10/05/22 at 02:30 PM, with Dietary Staff BB, revealed she would expect staff to clean the oven at least monthly and as needed, but she did not have a schedule for the cleaning and it had not been cleaned for approximately three months. The facility policy Cleaning Instructions: Oven, undated, instructed staff to regularly clean the ovens according to the cleaning schedule. The facility failed to ensure staff cleaned this oven used in food preparation…

    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 · F2022-10-06 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 36 residents. Based on observation and interview, the facility failed to ensure that staff contained trash in the dumpster and the lids to the dumpster were closed to prevent the spread of infection. Findings included: - Observation, on 10/05/22 at 03:15 PM, revealed the trash dumpster contained in a closed wooden gated enclosure. The dumpster lids were in an open position. Several broken open bags of trash which contained soiled incontinence briefs, peri-wipes and other used items lay directly on the ground that surrounded the dumpster. Interview, on 10/05/22 at 03:30 PM, with Maintenance Staff U, confirmed the open trash dumpster and open bags of trash. Maintenance Staff U stated staff should close the lids to the dumpster and ensure trash lands inside the dumpster. The facility policy Garbage and Rubbish Disposal, dated 04/06/22, instructed staff to ensure outside dumpsters are maintained in a clean and sanitary condition. The facility failed to contain trash in the dumpster with lids in a closed position to prevent the spread of infection.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-10-06 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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 reported a census of 36 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly environment in the storage closets that contained supplies for the residents of the facility. Findings included: - During an environmental tour on 10/06/22 at 11:30 AM with Housekeeping/Maintenance staff U, the following concerns were identified: A storage room on the 100- hall had two boxes of COVID rapid tests, two boxes of paper gowns, one box of five ounce (oz) plastic cups, with 2,500 cups per box, 1 box of 200 facial shields, a box with 20 graduates (containers to hold liquid), one box of 150 denture cups, one box of 48 urinals, one box with 20 rolls of toilet paper, ten boxes of briefs and pull-ups in varying sizes, and two boxes of 1,152 wipes. The nursing supply room on the 200- hall had one box of 3,000 facial tissues and one box of germicidal wipes, with 12 containers with 75 wipes in each container. On 10/06/22 at 11:30 AM, Housekeeping/maintenance staff U stated he was…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-06 · 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

    The facility reported a census of 36 residents. The 15 residents selected for review included three residents reviewed for quality of care including one resident for non-pressure wounds. Based on observation, interview and record review, the facility failed to provide adequate non-pressure wound care to resident (R)188 to prevent possible infection. Findings included: - Review of Resident (R)188's Electronic Health Record (EHR) Physician Orders, dated 09/30/22, revealed the resident admitted to the facility on (09/30/22). The resident had a diagnosis that included heart failure. The admission Minimum Data Set (MDS) was incomplete but in progress. The Baseline Care Plan dated 09/30/22 indicated the resident had current and a history of skin integrity issues, however, the baseline care plan lacked guidance for skin integrity concerns. The admission Assessment dated 09/30/22 indicated seven areas of concern that included areas on the resident's coccyx (small triangular bone at the base of the spine), and right and left gluteal fold (pertaining to the buttocks or buttocks muscles). 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 · Dcited before2022-10-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with 15 selected for review which included three residents reviewed for bowel and bladder/urinary tract infection. Based on observation, interview and record review the facility failed to provide sanitary peri-care for one resident (R) 5, of the three residents reviewed for bowel and bladder/urinary tract infections. Findings included: - Review of Resident (R)5's Physician Order Sheet, undated, revealed diagnoses included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease with dementia(progressive mental disorder characterized by failing memory, confusion), incontinence (inability to control urination and bowel movements), and hemiplegia (paralysis of one side of the body). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired mental status and required extensive assistance of two staff for bed mobility and toileting. The resident was frequently incontinent of bowel 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with 15 residents sampled, including one resident reviewed for respiratory needs. Based on interview, record review, and observation, the facility failed to obtain a physician order to appropriately administer oxygen to the one sampled Resident (R)27, who used oxygen. Findings included: - Review of Resident (R)27's electronic medical record (EMR), included a diagnosis of acute and chronic respiratory failure (a long-term lung disease in which oxygen is not absorbed correctly) and dependence on supplemental oxygen (a long-term condition requiring the use of a supplemental oxygen supply). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He received oxygen. The Cognitive Loss/Dementia Care Area Assessment' (CAA), dated 03/01/22, documented the resident was able to make his own needs and wants known and was able to make daily…

    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 · D2022-10-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with 15 selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to obtain a physician's order for the discontinuation of insulin for one Resident (R)4 of the five residents reviewed for unnecessary medications. Findings included: - Review of Resident (R)4's Physician Order Sheet, dated 08/19/22, revealed diagnoses included diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, and chronic (persisting for a long period, often for the remainder of a person's lifetime) kidney disease. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident received seven days of insulin. The Care Plan, reviewed 09/13/22, instructed staff to administer insulin as ordered…

    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 · D2022-10-06 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents, with 15 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to administer as needed (PRN) medications to one Resident (R)6 for lack of bowel movements (BM) and failed to obtain ordered labs for one Resident (R)17. Findings included: - The Physician Order Sheet (POS), dated 08/19/22, documented Resident (R)17 had diagnoses of hypertension (HTN-elevated blood pressure), type II diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (MDD-major mood disorder) and heart failure (inability for the heart to function appropriately). The resident's annual Minimum Data Set (MDS), dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. She had antipsychotic (medication used to treat psychosis) seven days of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-04-15 · tag F0628 — widespread
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interviews and record reviews, the facility failed to provide written notification to the Office of the Long-Term Care Ombudsman (LTCO) regarding six residents transferred from the facility, five transferred home and one resident transferred to another facility. Findings included:- Review of the admission/discharge report from 02/14/26 to 04/14/26 indicated one resident transferred to another facility and five residents transferred home. On 04/14/26 at 10:25 AM an interview with Social Service X revealed the only time she notifies the LTCO is when a resident is transferred to the hospital. She has not notified the LTCO with residents transferring to home or another facility. On 04/15/26 at 11:15 AM, an interview with Administrative Staff A revealed she expected any transfers from the facility to be sent to the ombudsman. The facility did not provide a policy regarding notification of the ombudsman on transfers to another facility or to home upon request.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-04-15 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the name of the facility and total hours worked, as required. Findings included:- Observed on 04/13/26 at 08:00 AM, the posted staffing sheet lacked the total hours worked. Observed on 04/14/26 at 09:30 AM, the posted staffing sheet lacked the total hours worked and did not list the facility name. Review of the daily staffing sheets from 05/13/25 and 03/18/26 revealed the posted staffing sheets lacked the total hours worked. During an interview on 04/14/26 at 11:48, Administrative Nurse D stated the nightshift nurse filled out the next day staffing sheet and then posted it for display before the start of the next shift. Administrative Nurse D also said the listed column that was labeled actual hours were the total hours worked. The facility policy Daily Nurse Staff Posting, dated 11/28/17, documented at the beginning of each shift the charge nurse would compute the number of full-time equivalents on duty…

    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

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

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

Fines & penalties

$16,355 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $16,355 — penalty dated 2026-05-19
  • Medicare payment denial — starting 2026-06-05 for 5 days

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

Part of a chain

This home belongs to MIDWEST HEALTH — 11 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 5 of 53.9+1.1 vs chain
Health inspection 3 of 53.4-0.4 vs chain
Staffing 5 of 54.1+0.9 vs chain
Quality measures 5 of 53.5+1.5 vs chain
The other 10 homes this chain runs (chain average 3.9★, 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
HALSTEAD HEALTH & REHAB CENTER OPERATIONS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 06/26/2003
FLOYD C EATON III TRUST 2012Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 07/01/2016
HALSTEAD HEALTH AND REHAB CENTER, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 06/26/2003
JAMES BRETT KLAUSMAN TRUST 2012Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 07/01/2016
JAMIE N EATON TRUST 2012Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 07/01/2016
KLATON HOLDINGS COMPANY INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 06/26/2003
MICHAEL GRAHAM KLAUSMAN TRUST 2012Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 07/01/2016
EATON, FLOYDIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 06/26/2003
KLAUSMAN, JAMESIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 06/26/2003
MIDWEST HEALTH, INC. 06122001OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2010

CMS files one row per role, so the 23 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$4.3M
Net patient revenuemost recent cost report
+7.9%
Operating marginrevenue minus expenses
$682K
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 5%Other / private 95%

This home reported $682K paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$255per resident / day
operating cost
$7,740per month
≈ monthly operating cost
$276per 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 175446. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, 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