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Good Samaritan - Hays

2700 Canal Blvd, Hays, KS 67601 · Non profit - Corporation · 45 certified beds · (785) 625-7331 Medicare & Medicaid certified

Call the home — (785) 625-7331 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 22 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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 5 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
600 Park St · (785) 628-4401 · Call to confirm hours
Pharmacy
Walgreens0.9 mi
2600 Vine St · (785) 628-1767 · Call to confirm hours
Grocery
Dillons<0.1 mi
515 W 27th St · (785) 628-1016 · Call to confirm hours
Park
2912 Willow 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 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 4 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 3 to 5 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 rating5★
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 increased24.1%17.9%15.4%worse
Long-stay residents who lose too much weight10.7%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection3.8%2.9%2.0%worse
Long-stay residents with depressive symptoms4.8%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 injury4.2%4.3%3.3%worse
Long-stay residents whose ability to walk worsened20.3%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication25.9%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine97.8%95.5%95.3%typical
Long-stay residents with pressure ulcers3.0%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control25.7%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table20.3%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents rehospitalized after admission10.8%22.4%22.6%better
Short-stay residents with an outpatient ER visit11.8%11.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.551.801.67typical
Long-stay outpatient ER visits per 1,000 resident days2.762.131.80worse

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.

46.9% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.9%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
39.1%U.S. median 56.6%
Met the expected recovery
0.11U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy

Met the expected recovery: 39.1% 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 23 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 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.9%CMS range 33.5–60.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 7.2–15.810.7%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 discharge39.1%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 discharge17.4%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 discharge43.5%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 identified95.7%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 stay0.0%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 worsened0.0%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 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 SNFs0.891.02Oct 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

0.88
RN hours/ resident / day
0.80
LPN hours/ resident / day
2.38
Aide hours/ resident / day
4.06
Total nurse hours/ resident / day
0.59
RN hoursweekends
28.8%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 45 beds and averages 41.5 residents a day — about 92% occupied, or roughly 4 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 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.53 hrs/resident/day on weekends vs 4.28 on weekdays — 18% thinner on weekends. RN hours go from 1.00 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below 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

5
deficiencies at the latest standard inspection (2025-02-24)
6
at the previous standard inspection (2023-05-15)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-08 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility failed to ensure Resident (R) 1 remained free from a significant medication error. On 05/05/2026, the Infectious Disease doctor, who was consulting on R1's Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcers on his gluteus (buttocks) and coccyx (area at the base of the spine), ordered fluconazole 400 milligrams (mg) twice a day for a bone biopsy culture, which revealed C. Albicans (a microscopic yeast and fungus which can cause fungal infections). The facility failed to initiate the medication until 05/23/2026. - Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), osteomyelitis (local or generalized infection of the bone and bone marrow) of the sacral (large triangular bone/area between the two hip bones) and coccygeal (relating to the coccyx) areas, Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics) to the pressure ulcers, Vancomycin-resistant…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-24 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 12 residents. Based on record review and interview, the facility failed to develop a discharge summary for one Resident (R) 44 reviewed for discharge that included a completed recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay. This deficient practice placed the resident at risk of receiving inadequate care. Findings included: - R44's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R44's Annual Minimum Data Set (MDS), dated 10/03/24, documented R44 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R44 was independent with most activities of daily living (ADL). The MDS documented R44 expected to be discharged to the community. R44's Care Plan, revised 09/12/23, documented R44 had developed independence and no longer required 24-hour care in a nursing home. The Nurse's Note, dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-24 · 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 12 residents, with two reviewed for urinary catheter or Urinary Tract Infection (UTI - Infection of any part of the urinary system). Based on observation, record review, and interview, the facility failed to provide appropriate care when staff failed to provide completed incontinent and catheter care for Resident (R) 3 after a bowel movement, before a dressing change, and who had a history of urinary tract infections. This deficient practice placed the resident at increased risk for UTI. Findings included: - R3's Electronic Medical Record (EMR) documented R3 had diagnoses of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying) and urine retention (lack of ability to urinate and empty the bladder). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had a Brief Interview of Mental Status (BIMS) of 14, which indicated intact…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-24 · 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 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 34's blood pressure medication was administered outside the physician-ordered parameters and the parameters were transcribed incorrectly. This placed the resident at risk for physical decline, related complications, and at risk for unnecessary drugs. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS), dated [DATE], documented R34 had moderately impaired cognition. R34 required supervision…

    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 before2025-02-24 · 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 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold and notify the physician of blood pressure medications per the physician-ordered parameters for one resident, Resident (R) 34. The facility also failed to transcribe physician-ordered parameters correctly. This deficient practice placed the resident at risk for physical decline, other related complications, and at risk for unnecessary drugs. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS), dated [DATE], documented R34 had moderately impaired cognition. R34…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-24 · 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 12 residents, with two reviewed for hospice services. Based on observation, record review, and interview, the facility failed to include a hospice plan of care with a description of the services provided which included contact information, visit frequency, medications, and medical equipment for Resident (R) 8. This deficient practice placed the resident at risk of not receiving needed care. Findings included: - R8's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and atherosclerotic heart disease of the native coronary artery (the buildup of plaque (fatty deposits) within the coronary arteries, which supply blood to the heart muscle). R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had short and long-term memory problems and severe cognitive impairment. The MDS document R8 was dependent on staff with oral and toileting hygiene,…

    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 before2023-05-15 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 41 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)16, and R28's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen with the date opened and expiration date, failed to discard R6's and R38's expired insulin vial and failed to discard expired stock medications on two medication carts. This placed the affected residents at risk for ineffective medications. Findings included: - On 05/09/23 at 08:45 AM, observation of Hall-One medication cart revealed the following: R28's Novolog (a short acting insulin) flex pen lacked a date opened, and date of expiration. R38 's Novolog flex pen opened 03/01/23, expired 03/29/23 (28 days). The medication cart revealed five individualized packets of famotidine (antacid) tablets, expired 09/2022. On 05/09/23 at 09:15 AM, observation of the Hall-Two medication cart revealed the following: R16's Tresiba (long acting insulin) flex pen open and undated. R6's Novolog vial opened 03/26/23, expired 04/23/23…

    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 before2023-05-15 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 41. The sample included 13 residents. Based on record review, interview and observation the facility failed to treat residents with respect, dignity, and privacy during blood glucose testing. This placed the resident at risk for impaired psychosocial wellbeing. Findings included: - On 05/09/23 at 11:25 AM, observation revealed Licensed Nurse (LN) H obtained Resident (R)6's blood sugar reading using a glucometer (a blood glucose meter monitor device that you test the amount of glucose [sugar] in the blood) from R6's right middle finger at the table in the dining room, with two other residents seated at the table and five other residents seated in the dining room eating lunch. On 05/15/23 at 09:30 AM, Administrative Nurse D stated staff should not check residents' blood sugar at the dining room table; they should take the resident to the room or to a private area. The facility's Resident's Right policy, dated November 2016, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-15 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 41 residents. The sample included 13 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing fluid restriction implementation for Resident (R) 16, who received dialysis treatment. This placed the resident at risk for complications and health decline. Findings included: - R16's Electronic Medical Record (EMR) recorded diagnoses of end stage renal disease (decline in kidney function.) R16's admission Minimum Data Set (MDS), dated 03/15/23, recorded R16 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS recorded he required extensive assistance of two staff for bed mobility, transfers, limited assistance of one staff with personal hygiene, and limited assistance of two staff with toilet use. The MDS further recorded R16 was frequently incontinent of urine and recorded the resident received dialysis…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-15 · 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 had a census of 41 residents. The sample included 13, with six reviewed for unnecessary medications. Based on record review and interview the facility failed to provide appropriate and adequate narcotic drug reconciliation, when staff failed to accurately record controlled substance doses on the narcotic count record and further failed to immediately report a discrepancy in Resident (R) 142's liquid Ativan (drug used to treat anxiety) count. This placed R142 at risk for missed, doses, misappropriation and/or diversion. Findings included: - R142's Electronic Medical Record (EMR) documented the resident had a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R142's Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score 13, which indicated intact cognition. The MDS documented R142 received an antianxiety medication for six days during the lookback period. R142'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
Show the remaining 12 citations
  • Potential for harm · Dcited before2023-05-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to ensure one of three residents, reviewed during medication administration pass, remained free of medication errors. This placed the resident at risk for adverse reaction from the medication. Findings included: - Resident (R)16's Electronic Medical Record (EMR) recorded diagnoses of end stage renal disease (decline in kidney function.) R16's admission Minimum Data Set (MDS), dated 03/15/23, recorded R16 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS recorded he required extensive assistance of two staff for bed mobility, transfers, limited assistance of one staff with personal hygiene, and limited assistance of two staff with toilet use. The MDS further recorded R16 was frequently incontinent of urine and recorded the resident received dialysis (procedure where impurities or wastes were removed from the blood) treatment. R16's Physician Order, dated 01/26/23 instructed staff 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-10-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 43 residents. Based on observation, interview, and record review the facility failed to store, prepare, and serve foods in a sanitary kitchen for the 43 residents of the facility. Findings included: - On 10/20/21 at 10:30 AM observation in the facility kitchen revealed: The Ice machine had brown, slimy substance on the inside surface which easily wiped off with a clean paper towel. The plate-holder cart had food crumbs in the bottom and in the one column without plates. The wall knife holder had dust and food crumbs on top, where the knives slide in. Three of eight overhead fluorescent lights had cracked plastic covers, one had visible lint on the surface. Three utensil drawers under the steam oven had dried food or liquid spills inside the drawer. The Kitchen Equipment Cleaning Log dated September/October 2021 documented, prior to 10/20/21, staff cleaned the ice machine 09/18/21. Staff cleaned the dish holder 10/06/21 and lacked documentation the wall knife holder was cleaned. On 10/20/21 at 10:30 AM, Dietary BB verified the ice machine needed cleaned.…

    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 · E2021-10-21 · 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

    - On 10/20/21 at 08:48 AM, Housekeeper U prepared to enter R38's room. She stated R38 had Methicillin-resistant Staphylococcus aureus (MRSA- a type of bacteria resistant to many antibiotics) in the urine. Housekeeper U prepared to enter R38's room by gathering cleaning supplies of broom, mop, dustpan, and cleaning cloths. She then donned (put on) a gown, gloves, and mask. She used appropriate cleaning products to sanitize MRSA. The rooms' hand washing sink, overbed table and cleansing cloths sprayed with Ecolab Peroxide Surface Cleaner and Disinfectant. Housekeeper U then wiped down the overbed table, handrail to the bed, oxygen concentrator, counter and sink, doorknobs, and light switches. Housekeeper U had not sprayed or wiped R38's wheelchair or vinyl recliner. Next the toilet was cleaned. The toilet, which was shared with a resident in the next room, had been sprayed with Ecolab Heavy Duty Alkaline Bathroom Cleaner and Disinfectant. Housekeeper U then mopped the contact precaution room floor and then the shared toilet room floor with the same mop head. On 10/21/21 at 08:48 AM,…

    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 before2021-10-21 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff applied a patch to Resident (R) 7's right shoulder at the dining room table, with five residents in full view. Findings included: - On 10/21/21 at 08:35 AM, observation revealed R7 seated at the dining room table eating breakfast. Licensed Nurse (LN) I approached the resident at the dining room table and explained to the resident she had to apply a patch, pulled her shirt down over the right shoulder then applied the patch, then pulled the shirt up and over the shoulder. Continued observation revealed five residents eating breakfast in the dining room. On 10/21/21 at 10:30 AM, Administrative Nurse D verified staff should not apply patches in the dining room and verified it was a dignity issue. The undated facility Resident Rights policy, recorded each resident shall have the right to personal privacy and confidentiality of personal and clinical records,…

    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 · D2021-10-21 · 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

    The facility had a census of 43 residents. The sample included 12 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide staff assistance with eating to Resident (R) 22, who required assistance of one staff for eating and who had a recent weight loss . Findings included: - R22's Physician Order Sheet, dated 09/23/21, documented diagnoses of major depressive disorder (MDD -abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion), anemia (lack of adequate of healthy red blood cells to carry adequate oxygen to the body's tissue), and atrial fibrillation (rapid, irregular heart beat). The ADL Care Plan, dated 08/17/21, documented the resident needed limited assistance of one staff with meals. On 10/20/21 at 07:40 AM, observation revealed the resident sat in wheelchair at the dining room table across from another resident eating breakfast. Continued…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census 43 residents. The sample included 12 residents with one reviewed for a decrease in activities of daily living (ADL) and mobility, Resident (R) 10. Based on record review, observation, and interviews, the facility failed to prevent a decline in functional ability for R10 when the facility failed to implement a restorative program. Findings included: - R10's Physician Order Sheet (POS), dated 09/21/21, documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (CVA- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) of right dominant side, need for assistance with personal care, muscle weakness, and reduced mobility. The admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, required extensive assistance of two staff for bed mobility and toileting, was totally…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-21 · 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 43 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to develop and implement effective nutritional interventions to prevent weight loss for one of five sampled residents, Resident (R) 22, who had a weight loss. Findings included: - R22's Physician Order Sheet, dated 09/23/21, documented diagnoses of major depressive disorder (MDD - abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion), anemia (lack of adequate of healthy red blood cells to carry adequate oxygen to the body's tissue), and atrial fibrillation (rapid, irregular heart beat). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. The MDS recorded the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-21 · 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 had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide the physician ordered medications for one of five sampled residents, Resident (R) 13. Findings included: - R13's Physician Order Sheet, dated 09/20/21, documented diagnoses of major depressive disorder (MDD - abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, and stage three kidney disease (kidney damage with mild to moderate loss of kidney function.) R13 's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition and received an antipsychotic and antidepressant, seven days of the assessment, and received an antianxiety…

    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 before2021-10-21 · 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 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the facility's consulting pharmacist (CP) identified and reported irregularities to the Director of Nursing, physician and medical director when the facility failed to obtain a physician ordered lab for Resident (R) 33. This placed R33 at increased risk of medication complications and side effects. Findings included: - The Physician Order Sheet (POS), dated 09/23/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), vitamin deficiency, and hypokalemia (low potassium level). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one which indicated severely 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-21 · 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 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain an ordered lab test for Resident (R) 33. This placed R33 at increased risk of medication complications and side effects. Findings included: - The Physician Order Sheet (POS), dated 09/23/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), vitamin deficiency, and hypokalemia (low potassium level). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one which indicated severely impaired cognition. She required limited to extensive assistance of one staff member for all activities of daily living (ADLs). The Care Plan dated 09/08/21 directed staff to review R33 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-21 · 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 — the official record, unedited, may be distressing

    The facility had a census of 43 residents. The sample included 12 residents. Based on observation and interview, the facility failed to label and dispense medication appropriately for Resident (R) 2, R14, and R21. Finding included: - On 10/18/21 at 09:11 AM, during initial tour, observation revealed Cottonwood Lane medication cart had multiple dose insulin pens which were not dated when opened for R2, R14, and R21 . On 10/18/21 at 09:11 AM, License Nurse (LN) H verified the insulin pens on the Cottonwood Lane medication cart had not been dated when opened for R2, R14, and R21. The facility's Medication Administration, Insulin Pens-Rehab/Skilled policy, dated 04/06/21, documented multidose vial should have an open date written on pen and to refer the insulin storage parameters for storage based on manufacture recommendations. The facility failed to date R2, R14, and R21, insulin pens when opened which placed the residents at risk for medication ineffectiveness and complications related to insulin use.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-05-15 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 41 residents. The sample included 13 residents. Based on record review and interview the facility failed to consistently deliver the 41 residents mail on Saturdays. Findings included: - On 05/11/23 at 11:30 AM, during resident council meeting, Resident (R) 26, R19, and R12 reported they had not consistently received their mail on Saturdays. On 5/11/23 at 8:34 AM, Activity Staff AZ verified the residents were not receiving mail on Saturdays. Activity Staff Z stated the mail is delivered on Saturday to the facility and placed in bucket in the entrance foyer. She said she picked it up on Mondays and delivered it to residents. Activity Staff Z stated the managers on duty take turns being in the facility on Saturdays, but some of them do not know who can have their mail or if it goes to the resident's representative. She stated there was a time when she was gone from the facility for two weeks and residents did not receive their mail during that time. Activity Staff Z stated on holiday weekends, there was no management on duty in the facility. She stated…

    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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to GOOD SAMARITAN SOCIETY — 92 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 53.0+2.0 vs chain
Health inspection 5 of 52.8+2.2 vs chain
Staffing 5 of 54.0+1.0 vs chain
Quality measures 3 of 52.8+0.2 vs chain
The other 91 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Edgebrook Care CenterEdgerton, MN 1 of 5Good Samaritan - IndianolaIndianola, IA 1 of 5Good Samaritan - Red OakRed Oak, IA 1 of 5Good Samaritan Society - AtkinsonAtkinson, NE 1 of 5Good Samaritan Society - BlackduckBlackduck, MN 1 of 5Good Samaritan Society - Grand Island VillageGrand Island, NE 1 of 5Good Samaritan Society - LakotaLakota, ND 1 of 5Good Samaritan Society - Mary Jane BrownLuverne, MN 1 of 5Good Samaritan Society - St Luke's VillageKearney, NE 1 of 5Good Samaritan Society - WindomWindom, MN 1 of 5Good Samaritan Society De SmetDe Smet, SD 1 of 5Good Samaritan Society MillerMiller, SD 1 of 5Salem Lutheran HomeElk Horn, IA 1 of 5Souris Valley Care CenterVelva, ND 1 of 5St Vincent's - A Prospera CommunityBismarck, ND 1 of 5Sunset Drive - a Prospera CommunityMandan, ND 2 of 5Good Samaritan - AtwoodAtwood, KS 2 of 5Good Samaritan - Decatur CountyOberlin, KS 2 of 5Good Samaritan - EsthervilleEstherville, IA 2 of 5Good Samaritan - MansonManson, IA 2 of 5Good Samaritan - OttumwaOttumwa, IA 2 of 5Good Samaritan - WaukonWaukon, IA 2 of 5Good Samaritan Society - BottineauBottineau, ND 2 of 5Good Samaritan Society - Hastings VillageHastings, NE 2 of 5Good Samaritan Society - OakesOakes, ND 2 of 5Good Samaritan Society - Park RiverPark River, ND 2 of 5Good Samaritan Society - Specialty Care CommunityRobbinsdale, MN 2 of 5Good Samaritan Society - St John'sKearney, NE 2 of 5Good Samaritan Society - St Martin VillageRapid City, SD 2 of 5Good Samaritan Society - SuperiorSuperior, NE 2 of 5Good Samaritan Society - Waconia And Westview AcreWaconia, MN 2 of 5Good Samaritan Society CantonCanton, SD 2 of 5Good Samaritan Society Luther ManorSioux Falls, SD 2 of 5Good Samaritan Society New UnderwoodNew Underwood, SD 2 of 5Good Samaritan Society Sioux Falls CenterSioux Falls, SD 2 of 5Good Samaritan Society Sioux Falls VillageSioux Falls, SD 2 of 5Good Samaritan-LiberalLiberal, KS 2 of 5The Good Samaritan Society-Kissimmee VillageKissimmee, FL 3 of 5Good Samaritan - AlgonaAlgona, IA 3 of 5Good Samaritan - DavenportDavenport, IA

Showing 40 of 91; lowest-rated first.

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
SANFORDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/2019
THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETYOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/2019
BROWN, GEORGEIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2025
DYKHOUSE, DANAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
ENGBRECHT, WESLEYIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
GASSEN, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 05/30/2024
GULSVIG, NEILIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
HERSETH SANDLIN, STEPHANIEIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
LUNDEEN, MARKIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
MCCAUSLAND, MAUREENIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2025
MOLBERT, LAURISIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
NORTH, ANDREWIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
SCHIEFFER, KEVINIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2025
SHULKIN, DAVIDIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
TEIKEN, BRENTIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
VENTLING-HERRMANN, MARNIEIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/30/2024
WENZEL, THOMASIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2025
FLUIT, JOELIndividualCORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 01/14/2026
MIDDLETON, AIMEEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/27/2022
OLSON, NICHOLASIndividualCORPORATE OFFICER; ADP OF THE SNFsince 04/08/2024
SCHEMA, NATHANIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2022
DE ANDRADE, PAULOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
GILLESPIE, JOSEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/15/2018
MORRISON, TONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
SANDGREN, DEEANDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2023
DTN STAFFING INCOrganizationADP OF THE SNFsince 08/02/2024
FOCUSONE SOLUTIONSOrganizationADP OF THE SNFsince 03/04/2024
GRAPE TREE MEDICAL STAFFING LLCOrganizationADP OF THE SNFsince 04/13/2018
OMNICARE LLCOrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 58 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$4.6M
Net patient revenuemost recent cost report
-1.1%
Operating marginrevenue minus expenses
$783K
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 11%Other / private 32%

This home reported $783K 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

$299per resident / day
operating cost
$9,094per month
≈ monthly operating cost
$296per 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 175322. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-24, 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.

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