Dawson Place
208 W Prout Street, Hill City, KS 67642 · Non profit - Other · 36 certified beds · (785) 421-3414 Medicaid only — no Medicare
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.5% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.9% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.3% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.2% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.7% | 0.0% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.8% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.6% | 16.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 26.2% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.2% | 22.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.3% | 18.1% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.59 | 1.80 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.72 | 2.13 | 1.80 | worse |
* 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.
Staffing
How full it usually is: this home is certified for 36 beds and averages 34.7 residents a day — about 96% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.65 on weekdays — 10% thinner on weekends. RN hours go from 0.55 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
35 citations, most serious first. The 11 most serious are shown; the remaining 24 are one tap away and print in full.
- Actual harm · G2022-10-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. The sample included 14 residents with four residents reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to identify and respond in a timely manner and failed to notify the Registered Dietician (RD) in effort to prevent a significant weight loss for Resident (R)23. As a result, R23 had an unplanned weight loss of 13.6 percent (%) over six months. Findings Included: - The Medical Diagnosis section within R23's Electronic Medical Records (EMR) included diagnoses of insomnia (difficulty with sleeping), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), epilepsy (brain disorder characterized by repeated seizures), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), lactose intolerance, osteoarthritis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-10-22 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 36 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure adequate daily nursing staff were always available to meet the needs of the residents who resided in the facility.Findings included:- The Facility Assessment, revised 06/23/25, documented the general approach to staffing was to ensure the facility had sufficient staff to meet the needs of the residents at any given time. The nursing staff were evaluated at the beginning of each shift and adjusted as needed (PRN) at the beginning of each shift and adjusted PRN to meet the care needs and acuity of the resident population.Review of the nursing daily staffing schedules from 07/01/24 to 09/29/24 revealed on 08/10/24 and 09/21/24 a lack of licensed nurse coverage 24 hours a day.On 10/21/25 at 08:37 AM, Administrative Staff A stated she was responsible for completing the daily nurse staffing schedules. Administrative Staff A stated Administrative Nurse D worked on the days above in the missing time slot. Administrative Staff 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.
- Potential for harm · Fcited before2025-10-22 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 36 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide the services of a full-time certified dietary manager for the 36 residents who resided in the facility and received their meals from the kitchen. Findings included:- On 10/20/25 at 08:20 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 10/20/25 at 08:30 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had five residents with a mechanical soft diet. On 10/22/25 at 01:00 PM, Administrative Staff A verified Dietary Staff BB was not certified.The facility's Dietician policy, undated, documented that a qualified, competent, and skilled dietician would help oversee the food and nutrition services in the facility. A food and nutrition services manager will oversee the production, storage, and delivery of food. The dietician will work closely with the food and nutrition service manager and clinical staff. Dietary managers who are not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-10-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 36 residents. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in the facility's kitchen. Findings included:- On 10/21/25 at 11:30 PM, during food preparation, observation revealed the following:1. Three overhead fluorescent light fixtures, four feet by 12 inches with two light bulbs in each fixture, located directly above the food preparation area, and three overhead fluorescent light fixtures, four feet by 18 inches with four light fixtures, located above the dishwashing area and hot food preparation area with grey hanging lint.2. Three 24-inch by 24-inch air vent grills located above the cooking stove and food prep area, covered with brownish grease/sticky substance and gray fuzzy substance blowing directly on the food preparation and stove cooking area.3. One 24-inch by 24-inch, exhaust vent located above the dishwashing area, grills covered with brownish/black sticky grease substance and black fuzzy substance.4. 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.
- Potential for harm · Fcited before2025-10-22 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 36 residents. The sample included 12 residents. The facility had four residents required to be on enhanced barrier precautions (EBP- interventions designed to reduce the transmission of multi-drug-resistant organisms (MDRO- microorganisms, primarily bacteria, that have developed resistance to multiple antibiotics) during high contact resident care activities). Based on observation, interview, and record review, the facility failed to ensure that EBP signage was posted in or near the residents' rooms, which communicated the types of precautions and the personal protective equipment (PPE) required before performing resident cares. Findings included:- On the initial tour of the facility on 10/20/25 at 08:20 AM, four residents had PPE inside their rooms. Resident (R) 8, R11, R17, and R19 rooms had evidence of PPE in the room, but lacked signage inside or outside of the rooms that indicated that a resident was on EBP.On 10/20/25, a list of the residents on EBP was requested and provided by Administrative Nurse E. The list documented that R8, R11, R17,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-22 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 36 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R) 7's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. Findings include: - R7's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes persistent feelings of sadness), and sleep apnea (a disorder of sleep characterized by periods without respirations).R7's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R7 had severely impaired cognition. The MDS recorded R7 required staff assistance with most…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-22 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 12 residents, with two residents reviewed for hospitalization. Based on observation, interviews, and record review, the facility failed to provide a written notification of transfer to Resident (R) 5 or their representative for all applicable transfers/discharges. The facility failed to ensure the written notification of transfers given to R5 had the required information. The facility further failed to notify the State Long Term Care Ombudsman (LTCO) of transfers/discharges for R5. Findings included:- R5's Electronic Medical Record (EMR) documented diagnoses of overactive bladder (a condition characterized by frequent, sudden, and uncontrollable urge to urinate, often accompanied by urinary incontinence), chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample size included 12 residents, who were reviewed for care plans. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 3's care plan was revised and interventions implemented to direct staff on resident care for her insulin pump (a small, computerized device that delivers insulin through a thin tube inserted under the skin).Findings included:- R3's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin).R3's Annual Minimum Data Set (MDS) dated [DATE], documented R3 had a Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-22 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 36 residents. The sample included 12 residents, with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility's consultant Pharmacist failed to obtain an approved indication for use for Seroquel (antipsychotic -class of medications used to treat psychosis and other mental emotional conditions) for Resident (R) 7, and Risperdal (antipsychotic) for R7, and failed to have monthly pharmacy Medication Regimen Reviews (MRR) for R3 and R4. Findings included:- R7's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes persistent feelings of sadness), and sleep apnea (a disorder of sleep characterized by periods without respirations). R7's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R7 had severely impaired cognition. The MDS recorded R7 required staff assistance with most activities of daily living (ADL).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-10 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to conduct or implement nursing competencies required for residents' care needs, as identified through resident assessments and plans of care. This placed the residents at risk for decreased quality of care. Findings included: - On 07/10/24 at 11:15 AM, Certified Medication Aide (CMA) R stated the facility had not provided any competency skill checks with her. On 07/10/24 at 11:15 AM, Certified Nurse Aide (CNA) O stated the facility had not provided any competency skills checks with him. On 07/10/24 at 09:30 AM, Administrative Nurse D verified she had not performed any competency checks with the staff. The June 24, 2024 Facility Assessment included the resident population profile, resident acuity profile, staff training, licensing, and required continuing education. The assessment recorded the facility would provide ongoing education and staff training. The staff training and education program is designed to ensure knowledge competency for all staff.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-10 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to employ a full-time certified dietary manager for the 32 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 07/09/24 review of the noon meal consisted of baked honey-glazed ham, oven-browned potatoes, seasoned green beans, and Amish sugar cookies. On 07/09/24 at 10:20 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 07/09/24 at 10:20 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had completed the classes but was not scheduled for the exam. On 07/10/24 at 09:07 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's Food and Nutrition Services, undated, documented the facility would employ a qualified, registered dietitian or other clinically qualified 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.
Show the remaining 24 citations
- Potential for harm · Fcited before2024-07-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 33 residents. The facility had one kitchen. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, in one of one kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 07/08/24 at 07:28 AM, observation in the kitchen revealed the following: In the walk-in refrigerator, an unlabeled, undated container with 10 green peppers had a white substance on it. Dietary Staff (DS) CC verified the finding and discarded the green peppers. DS CC stated they were molded, and the fresh vegetables were not staying fresh like they should. In the area by the walk-in refrigerator, two loaves of whole grain bread with an expiration date of 07/06/24. DS DD verified the finding and discarded the loaves of bread. On 07/09/24 at 10:20 AM, observation in the kitchen revealed the upper white metal cabinets above the three-sink had numerous size brownish-black…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. Based on observation, record review, and interview, the facility failed to implement Enhanced Barrier Precautions (EBP-an infection control practice that uses personal protective equipment (PPE) to reduce the spread of multi-drug resistant organisms (MDROs) for Resident (R) 10 who had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and R3 who had an enteral (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food) feeding tube while providing direct care contact. The facility also failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). These deficient practices placed the facility's residents at risk of contracting or spreading infectious processes. Findings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such 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 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide effective pain management for Resident (R) 15, who experienced pain. This deficient practice placed R15 at risk for ongoing pain and impaired quality of life. Findings included: - R15's Electronic Medical Record (EMR) included diagnoses of bilateral osteoarthritis (chronic arthritis without inflammation) of the knee, constipation (difficulty passing stools), chronic pain, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), pain in the right and left knee, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and hypertension (HTN-elevated blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R15 had moderately impaired cognition and had verbal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide regular in-service education based on the outcome of performance reviews and failed to ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk for impaired care. Findings included: - The facility's employment records documented 5 nurse aides were employed at the facility for at least one year. The facility's in-service records documented that three of those nurse aides had not completed the required 12 hours of in-service training in the past year. On 07/09/24 at 09:30 AM, Administrative Nurse D stated she had a system in place to monitor the completion of in-service hours, but it was not up to date and failed to provide the needed hours for the by nurse aide staff. On 07/09/24 at 04:00 PM, Administrative Staff A stated they were unaware there was no system in place to monitor the completion of in-service hours. Administrative Staff A said the facility was implementing 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.
- Potential for harm · Dcited before2024-07-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 33 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of a 14-day stop date or specific duration with physician rationale for Resident (R) 14 and R33's as needed (PRN) psychotropic (alters mood or thoughts) medication. This placed the resident at risk for unnecessary medication with side effects. Findings include: - R14's Electronic Health Record (EHR) revealed diagnosis of protein-calorie malnutrition (inadequate intake of food and other essential nutrients that result in changes to the body composition and function), hypertension (HTN-elevated blood pressure, chronic kidney disease (mild to moderate damage and they are less able to filter waste and fluid from your body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia (progressive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or specified duration with physician rationale for Resident (R)14's, R16's, and R33's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R14, R16, and R33 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R14's Electronic Health Record (EHR) revealed diagnosis of protein-calorie malnutrition (inadequate intake of food and other essential nutrients that result in changes to the body composition and function), hypertension (HTN-elevated blood pressure, chronic kidney disease (mild to moderate damage and they are less able to filter waste and fluid from your body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0849 — isolatedArrange 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 33 residents. The sample included 12 residents with two reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)14 and R 16. This placed R14 and R16 at risk for inappropriate end-of-life care. Findings included: - R14's Electronic Health Record (EHR) revealed diagnosis of protein-calorie malnutrition (inadequate intake of food and other essential nutrients that result in changes to the body composition and function), hypertension (HTN-elevated blood pressure, chronic kidney disease (mild to moderate damage and they are less able to filter waste and fluid from your body), anxiety (mental 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.
- Potential for harm · D2024-07-10 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. Based on interview and record review, the facility failed to consistently utilize an antibiotic stewardship program that included tracking, monitoring, and attempts to decrease the use of unnecessary antibiotic (a class of medications used to treat infections) treatments which placed Resident (R) 17 at risk of adverse outcomes associated with the inappropriate use of antibiotics and development of antibiotic-resistant organisms. Findings included: - R17's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), schizoaffective (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) disorder bipolar type (major mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. Based on the interview and record reviews the facility failed to offer pneumococcal (type of bacterial infection) PCV20 immunizations for Residents (R) 3, R4, and R19 per the guidance from the Centers for Disease Control and Prevention (CDC) This placed the residents at risk for pneumococcal infection. Findings included: - R3's Electronic Health Record (EHR) documented i R3 received one Pneumovax dose on 10/09/18. The facility lacked documentation R3 was offered or refused any further pneumococcal vaccinations. R4's EHR documented R4 received one Pneumovax dose on 04/12/22. The facility lacked documentation R4 was offered or refused any further pneumococcal vaccinations. R19's EHR documentation indicated R19 received one Pneumovax dose on 04/12/22. The facility lacked documentation R19 was offered or refused any further pneumococcal vaccinations. During an interview on 07/09/24 at 03:01 PM, Administrative Nurse E and F verified the three residents had not received or been offered a second pneumonia immunization since admission to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-10-13 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to develop corrective actions plans and monitor them to correct identified quality deficiencies prior to survey. This deficient practice placed the resident's at risk for ineffective care. Findings Included: - The facility failed to provide the resident or resident's responsible party with a lawfully recognized Out of Hospital Do Not Resuscitate (DNR-an order to withhold resuscitative measures) advance directive form for Resident (R) 3, which placed her at risk for R3's choice for a DNR not being honored (Refer to F578) The facility failed to notify R20's representative of her elopement (when a cognitively impaired resident exits the facility without staff knowledge or supervision) from the facility. (Refer to F580) The facility failed to identify and report a potential allegation of neglect for R20 to the State Agency (Refer to F609) The facility failed to investigate an elopement when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 identified a census of 26 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to provide the resident or resident's responsible party with a lawfully recognized Out of Hospital Do Not Resuscitate (DNR-an order to withhold resuscitative measures) advance directive form for Resident (R) 3, which placed her at risk for R3's choice for a DNR not being honored. Findings included: - R3's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS) dated [DATE] documented R3 had a severely impaired memory. The MDS documented that R3 required extensive assistance of two staff members for activities of daily living (ADL's). The Quarterly MDS dated [DATE] documented R3 had a severely impaired memory. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. The sample included 14 residents with eight reviewed for notification of changes. Based of observations, record review, and interviews, the facility failed to notify Resident (R) 20's representative of her elopement (when a cognitively impaired resident exits the facility without staff knowledge or supervision) from the facility. This deficient practice placed R20 at risk for complications related to delayed decisions regarding treatment and services. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), pseudobulbar effect (emotional disturbance characterized by uncontrollable episodes of crying, laughing, anger or other emotional displays), mood disturbances, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. The sample included 14 residents with three reviewed for reporting of alleged violations. Based of observations, record review, and interviews, the facility failed to identify and report a potential allegation of neglect for Resident (R) 20 to the State Agency. This placed the resident at risk for unidentified and ongoing abuse and /or neglect. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), pseudobulbar effect (emotional disturbance characterized by uncontrollable episodes of crying, laughing, anger or other emotional displays), mood disturbances, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disturbances, major depressive disorder (major mood disorder),and spondylolisthesis (movement of the spinal bones…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. The sample included 14 residents with three reviewed for potential neglect. Based of observations, record review, and interviews, the facility failed to investigate an elopement (when a cognitively impaired residnet leaves the facility without staff knowledge and supervision) when Resident (R) 20 exited the facility without staff supervision or knowledge. This deficient practice placed R20 at risk for unidentified and ongoing neglect. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), pseudobulbar effect (emotional disturbance characterized by uncontrollable episodes of crying, laughing, anger or other emotional displays), mood disturbances, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disturbances, major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 26 residents. The sample included 14 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-intiated transfer to Resident (R)16 or her representative. This deficient practice placed R16 at risk of delayed care or uncommunicated care needs. Findings included: - R16 admitted on [DATE] and discharged on 09/16/22. R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The admission Minimum Data Set (MDS) dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. The sample included 14 residents with eight reviewed for accidents. Based of observations, record review, and interviews, the facility failed to prevent an elopement (when a cognitively impaired residnet leaves the facility without staff knowledge and supervision) when Resident (R) 20 exited the facility without staff supervision or knowledge. This deficient practice placed R20 at risk for accident related injuries. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), pseudobulbar effect (emotional disturbance characterized by uncontrollable episodes of crying, laughing, anger or other emotional displays), mood disturbances, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disturbances, major depressive disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 26 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure the required physician visits for Resident (R) 2, which placed her at risk of unrealized changes in R2's condition leading to unnecessary complications in her wellbeing. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and pain. The Annual Minimum Data Set (MDS) dated [DATE] documented severely impaired cognition. The MDS documented that R2 was dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R2 was a risk for skin issues during the look back period. The Quarterly MDS dated 08/24/22 documented R2 had severely impaired cognition. The MDS documented that R2 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.
- Potential for harm · Dcited before2022-10-13 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 26 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure the nursing staff providing care had the appropriate competencies and skills necessary for use of hot compresses for Resident (R) 2. The facility further failed to ensure staff possessed the appropriate skills and competencies when staff failed to assess R20 after an elopement (when a cognitively impaired resident exits the facility without staff supervision or knowledge). The deficient practice placed these residents at risk of resident safety, marinating their highest practicable physical, mental, and psychosocial well-being of each resident. Findings Included: - R2's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and pain. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. The sample included 14 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interviews, the facility failed to provide individualized care and services related to dementia care for Resident (R)15 and R20. This deficient practice placed both residents at risk for decreased psychosocial wellbeing and injuries. Findings Included: - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of dementia , anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), insomnia (inability to sleep), paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and major depressive disorder (major mood disorder). A review of R15's Minimum Data Set (MDS) dated 07/06/22 noted a Brief Interview for Mental Status (BIMS) assessment could not be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-13 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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
The facility identified a census of 26 residents. The sample included 14 residents with five residents reviewed unnecessary medications. Based on observation, record review, and interviews, the facility failed to acknowledge and follow the Consultant Pharmacist's (CP) recommendations for Resident (R)15's psychotropic (a class of medications which affect mood or thoughts) medication. This deficient practice placed R15 at risk for ineffective treatment and unnecessary side effects. Findings included: - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), insomnia (inability to sleep), paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and major depressive disorder (major mood disorder). A review of R15's Annual Minimum Data Set (MDS) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-13 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 26 residents. The sample included 14 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure pulse monitoring for Resident (R) 25's hypertensive betablocker medication (class of medication used to treat high blood pressure). This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R25's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure) and atrial fibrillation (rapid, irregular heart beat). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R25 was independent with activities of daily living (ADL's). The MDS documented R25 had received anticoagulant medication (-class of medications used to prevent 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.
- No harm found · C2025-10-22 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 36 residents. Based on the interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4 2024 (July 1- September 30) indicated the facility had no licensed nurse coverage 24 hours a day on the following dates: 07/07/24, 07/27/24, 07/28/24, 08/11/24, and 09/29/24.Review of the facility's daily nursing staff coverage revealed the facility had licensed nurse coverage 24 hours a day on the above dates, and revealed the facility had adequate licensed nurse coverage.On 10/21/25 at 08:37 AM, Administrative Staff A stated the human resource staff was responsible for submitting the PBJ during that period of time, and she no longer worked for the facility.The facility's Reporting Direct Care Staffing Information (PBJ) Policy, revised May 2024, documented that complete and accurate direct care staffing information would be reported electronically…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-07-10 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure one of two kitchen ovens was in safe and operable condition. Findings included: - On 07/09/24 at 10:20 AM, observation revealed in the kitchen one oven was not working. On 07/09/24 at 10:20 AM, Dietary Manager (DM) BB verified one oven was not working and stated it had a gas leak so a company came in and capped it off approximately 1.5 years ago. DM BB stated it was on the list to be replaced. On 07/10/24 at 09:07 AM, Administrative Staff A stated she was unaware one of the kitchen ovens was not working. She stated she knew the dietary manager had put in for a grant to update the kitchen but ended up not qualifying for the grant. Administrative Staff A was unaware of a kitchen repair list. Administrative Staff A stated she would notify the facility board. Upon request, the facility did not provide a preventative maintenance policy. The facility failed to maintain all mechanical, electrical, and resident care equipment in safe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2022-10-13 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 26 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to retain the daily posted nursing staffing data for the 18 months as required. Findings included: - Review of the daily posted nursing staffing data provided by the facility lacked any posted nursing staffing data from April 2021 through January 2022 (306 days). Review of posted nursing staffing data from 02/01/22 through 10/11/22 (253 days) lacked following dates (76 days) : 02/04/22, 02/05/22, 02/25/22, 03/01/22, 03/02/22, 03/03/22, 03/09/22, 03/10/22, 03/11/22, 03/13/22, 03/14/22, 03/18/22, 03/19/22, 03/23/22, 03/24/22, 03/28/22, 03/29/22, 03/31/22, 04/05/22, 04/07/22, 04/12/22, 04/14/22, 04/19/22, 04/26/22, 04/29/22, 05/02/22, 05/06/22, 05/10/22, 05/13/22, 05/19/22, 05/20/22, 05/24/22, 05/25/22, 05/30/22, 06/03/22, 06/10/22, 06/17/22, 06/25/22, 06/30/22, 07/09/22, 07/13/22, 07/17/22, 08/01/22, 08/11/22, 08/12/22, 08/14/22, 08/19/22, 08/20/22, 08/23/22, 08/24/22, 08/27/22, 08/30/22, 09/02/22, 09/03/22, 09/04/22, 09/06/22,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in KS
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 17E451. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-22, 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.