Sheridan County Hospital Ltcu

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

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.

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.

Therapy staffing: this home’s payroll records show 0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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.

Staffing

How full it usually is: this home is certified for 32 beds and averages 25.0 residents a day — about 78% occupied, or roughly 7 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.37 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.68 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 4.38 hrs/resident/day on weekends vs 6.02 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 1.58 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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 more than at the previous inspection — worsening. 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.

20 citations, most serious first. The 13 most serious are shown; the remaining 7 are one tap away and print in full.

• Actual harm · Gcited before2024-11-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility identified a census of 26 residents, with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to transfer Resident (R) 1 safely with a gait belt, and in the process of the transfer staff lifted R1 by both of her arms and R1 sustained a broken left humerus (upper arm bone). This deficient practice placed R1 at risk for injury, pain, and delayed healing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and lymphedema (swelling caused by accumulation of lymph). The Quarterly Minimum Data Set (MDS), dated 10/14/24, documented R1 had a Brief Interview for Mental Status score of four which indicated severely impaired cognition. The MDS documented R1 had impairment on one side of her…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample included 13 residents with eight reviewed for falls. Based on observation, record review, and interview the facility failed to ensure an environment free from accidents when staff placed Resident (R) 4's electric lift chair remote in reach, despite a safety evaluation which indicated it was not safe. As a result, R4 fell and required sutures to her head laceration. The facility continued to leave the lift control within R4's reach, which placed her at continued risk for falls, injuries, and associated pain. Findings included: - R4's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure) with heart failure, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), weakness, and repeated falls. The Quarterly Minimum…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-07-14 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot care.
  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 28 residents. The sample included 12 residents with one resident reviewed for foot care. Based on observation, record review, and interview the facility staff failed to provide appropriate foot care in accordance with professional standards of practice, to prevent complications from conditions such as diabetes, when a Certified Nurse Aide (CNA) filed Resident (R) 15's callous on her right big toe, which caused a wound. As a result. R15's wound became infected, required medical treatment including antibiotics, and continued to cause R15 pain. Findings included: - R15's Electronic Medical Record documented the resident had diagnose of type II diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R15's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score 14, which indicted intact cognition. The MDS documented R15 required supervision with transfers,…

  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 · F2025-10-22 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility had a census of 27 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week.Findings included:- The Payroll Based Journal (PBJ- a required detail of staffing information submitted by nursing homes, provided by the Centers for Medicare and Medicaid Services (CMS)) documented that the facility lacked RN eight-hour coverage for the following days: 04/19/25, 05/10/25, 05/17/25, and 05/24/25.On 10/21/25 at 04:00 PM, Administrative Nurse D verified on the above dates that there was no RN in the Long-Term Care Unit, but that there was an RN on call.On 10/22/25 at 07:55 AM, Administrative Staff A stated that a report was run after accounts payable received the timesheet. There had been times when they did not get the agency staff timesheets before submitting the PBJ, so that was probably the glitch. Administrative Staff A further stated they have since changed systems, and the agency staff can clock in to track their time better. Upon…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-22 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent 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 27 residents. The sample included 12 residents, with seven reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 25 was free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without an appropriate indication for use. Findings included: - R25's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), moderate dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic disturbance (gross impairment in reality perception), restlessness, and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition).R25's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-10-22 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 11 and R27, who received prophylactic antibiotics for urinary tract infections (UTI- an infection in any part of the urinary system).Findings included: - R11's Electronic Medical Record (EMR) documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and paranoid schizophrenia (characterized by persistent delusions of persecution, grandeur, or jealousy, often accompanied by auditory hallucinations). R11's admission Minimum Data Set (MDS) dated [DATE] documented R11 had moderately impaired cognition. R11 was dependent upon staff assistance for toileting hygiene and was frequently…

  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 · D2025-10-22 · 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 27 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility's Consultant Pharmacist (CP) failed to address with the facility the ongoing prophylactic (a medicine or course of action used to prevent disease) antibiotic (a class of medications used to treat infections) use for Resident (R) 11 and R27.Findings included: - R11's Electronic Medical Record (EMR) documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and paranoid schizophrenia (characterized by persistent delusions of persecution, grandeur, or jealousy, often accompanied by auditory hallucinations). R11's admission Minimum Data Set (MDS) dated [DATE] documented R11 had moderately impaired cognition. R11…

  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 · D2025-10-22 · 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 27 residents. The sample included 12 residents, with one reviewed for Hospice (specialized end-of-life) services. Based on observation, interview, and record review, the facility failed to provide thorough care planning instruction for Resident (R) 7, who received Hospice services. Findings included:- R7's Electronic Medical Record documented a diagnosis of Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder).R7's Quarterly Minimum Data Set (MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) without a score and documented R7 had severely impaired cognition. The MDS documented R7 was dependent on staff for all activities of daily living and received Hospice services. R7's Care Plan dated 10/13/25 stated his family had elected Hospice services. R7's weight would be obtained monthly for Hospice to monitor. The care plan included the hospice phone number but…

  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 · D2025-10-22 · tag F0881 — failed to use antibiotics responsibly — isolated
  Implement 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 27 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse effects, including antibiotic resistance, when the facility failed to monitor effectiveness and evaluate appropriateness for the extended administration of prophylactic (preventative in nature) antibiotics for Residents (R) 11 and R27.Findings included:- R11's Electronic Medical Record (EMR) documented diagnoses of retention of urine (lack of ability to urinate and empty the bladder), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and paranoid schizophrenia (characterized by persistent delusions of persecution, grandeur, or jealousy, often accompanied by…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-05-23 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for 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) and other waterborne pathogens. The facility staff failed to change gloves while providing incontinent care for R23. This placed the residents in the facility at risk for infectious disease. Findings Included: - On 05/22/24 at 08:51 AM, Administrative Nurse D stated she was unaware of what the facility's measures were to prevent the growth of Legionella and other waterborne pathogens in building water systems. Administrative Nurse D said the emergency preparedness manager at the hospital might be in charge of the plan but would 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-23 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample included 13 residents with one reviewed for dignity. Based on observation, record review, and interviews, the facility staff failed to treat Resident (R) 17 with dignity when staff failed to close the window curtain during personal care of a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This placed the resident at risk for an undignified experience and embarrassment. Findings included: - R17's Electronic Medical Record (EMR) documented R17 had a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord) R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R17 was dependent on staff for most activities of daily living (ADLs). R17 had a feeding tube. R17's Care Plan, revised 02/26/24, instructed staff to administer all of R17'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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 23 residents. The sample included 13 residents, of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 9's as needed (PRN) Xanax (an antianxiety medication that calms and relaxes people with excessive restlessness, nervousness, and tension) had a 14-day stop date and or a rationale for extended use with a specified stop date. This placed R9 at risk of receiving unnecessary psychotropic medications (medications that affect the chemical makeup of the brain). Findings included: - R9's Electronic Medical Record (EMR) recorded a diagnosis of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R9's Annual Minimum Data Set (MDS), dated [DATE], recorded R9 had a Brief Interview for Mental Status (BIMS) score 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-02-06 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility identified a census of 29 residents with three reviewed for accidents. Based on record review, observation, and interview, the facility failed to update Resident (R) 1's Care Plan to include staff using a gait belt to assist R1 when standing from a seated to a standing position after Certified Nurse's Aide (CNA) M did not use a gait belt causing bruises and pain. This deficient practice placed R1 at risk for unsafe transfers due to uncommunicated care needs. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), repeated falls, and chronic respiratory failure. The Annual Minimum Data Set (MDS), dated 12/27/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R1 had impairment on one side of her body of both the upper and lower extremities and utilized a walker and a wheelchair. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA),…

  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

“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.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

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