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Diversicare Of Hutchinson

1202 E 23rd Avenue, Hutchinson, KS 67502 · For profit - Limited Liability company · 73 certified beds · (620) 669-9393 Medicare & Medicaid certified

Call the home — (620) 669-9393 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citations — no harm found (F0744, F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,376 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,376 in federal fines (most recent 2024-09-05)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2803 N Lorraine St, Suite D
Pharmacy
1600 N Lorraine St Ste 100 · (620) 921-3013 · Call to confirm hours
Grocery
901 E 30th Ave · (620) 669-9309 · Call to confirm hours
Park
2101 N Severance St · (620) 694-1900 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.6%17.9%15.4%better
Long-stay residents who lose too much weight2.8%4.9%5.4%better
Long-stay residents with a catheter left in their bladder0.6%1.6%0.9%better
Long-stay residents with a urinary tract infection0.4%2.9%2.0%better
Long-stay residents with depressive symptoms0.0%6.5%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.7%4.3%3.3%worse
Long-stay residents whose ability to walk worsened16.5%16.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication8.0%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine98.5%95.5%95.3%typical
Long-stay residents with pressure ulcers0.4%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control20.1%22.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table15.1%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%73.8%79.4%better
Short-stay residents rehospitalized after admission19.2%22.4%22.6%better
Short-stay residents with an outpatient ER visit5.5%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.231.801.67worse
Long-stay outpatient ER visits per 1,000 resident days1.852.131.80typical

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

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

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

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

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

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

47.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.9%U.S. median 51.5%
Got home and stayed home
8.6%U.S. median 10.7%
Went back to hospital
54.0%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 54.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.9%CMS range 35.8–59.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.6%CMS range 5.9–12.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge48.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.5–14.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.59
RN hours/ resident / day
0.49
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.30
Total nurse hours/ resident / day
0.29
RN hoursweekends
38.5%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 73 beds and averages 68.5 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.78 hrs/resident/day on weekends vs 3.51 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.72 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-01-30)
13
at the previous standard inspection (2023-03-27)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 64 residents, which included one resident reviewed for accidents and identified 12 residents that were confused and independently mobile. Based on observation, interview, and record review the facility failed to ensure cognitively impaired Resident (R)1 remained free from accident hazards when on 07/15/24 at approximately 10:15 AM, R1 left the facility through an unsecured gate in the west courtyard. R1 remained unsupervised until Law Enforcement Officers (LEO) contacted R1 outside of a local business, located approximately 2.8 miles away from the facility, at 11:10 AM (55 minutes after R1 left the facility unsupervised and without staff knowledge). R1 did not return to the facility until approximately 11:25 AM (one hour and 10 minutes after R1 left the facility). This deficient practice had the potential to lead to serious bodily harm to R1 and placed R1 in immediate jeopardy. Findings included: - The Electronic Health Record (EHR) for R1 included the following diagnoses:…

    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
  • Potential for harm · D2026-02-24 · tag F0744 — failed to care for residents with dementia — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 37 residents. The sample included seven residents, with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion), care, and services. Based on observation, record review, and interviews, the facility failed to initiate a dementia plan of care that identified and honored Resident (R) 1's desire for physical engagement, which included direction to staff on how to identify voluntary engagement, and how to monitor for potential negative outcomes associated with physical engagement. Findings included:- R1's Electronic Health Record (EHR) under the Census tab documented R1 admitted to the facility on [DATE].R1's EHR revealed diagnoses of dementia, major depressive disorder (a major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and unspecified sexual dysfunction.R1's 09/28/25 Modified admission Minimum Data Set (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-30 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 70 residents. Based on observation and interview, the facility failed to ensure a clean, safe, homelike environment for the residents who ate in the dining room and the residents who resided on two of the four resident halls. Findings included: - On 01/30/25 at 08:55 AM, observation during a tour of the facility revealed the following: The dining room floor had a broken tile with a missing piece, approximately five by six inches. The dining room exit to the east had missing door trim, and the foam insulation was visible. The dining room wall behind the ice machines had a hole, approximately one foot by two and a half feet, with the inside wall and pipes visible. The northwest resident hall had numerous damaged or ill-fitting ceiling tiles. The northeast resident hall had numerous damaged or stained ceiling tiles. The northeast hall shower room had a framed hole in the wall, approximately 15 by 15 inches, with the pipes and inner wall visible. On 01/30/25 from 08:55 to 09:05 AM, Administrative Staff A verified the findings and stated the facility had 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · 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 71 residents. The sample included 18 residents, with five residents reviewed for falls and accidents. Based on observation, record review, and interviews, the facility failed to implement grip strips in front of Resident (R) 20's toilet and failed to implement anti-rollbacks on his wheelchair. This deficient practice placed R20 at risk for future preventable falls. Findings Include: - R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hyperlipidemia (condition of elevated blood lipid levels), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), overactive bladder, dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion),…

    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 · D2025-01-30 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 71 residents. The sample included 18 residents, with three residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 7 and R62 posttraumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R7 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R7's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of posttraumatic stress disorder, lupus (an autoimmune disease that makes the immune system damage organs and tissue throughout the body), altered mental status, rheumatoid…

    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 · D2025-01-30 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 70 residents. The sample included 18 residents, with two reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R) 8 and R62. This deficient practice placed R8 at risk for preventable injury. Findings included: - The Electronic Medical Record (EMR) for R2's diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), cerebrovascular accident (CVA -stroke- 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), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R8's Annual Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · 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 70 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported an inappropriate indication for the use of an antipsychotic medication (a class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R) 5. This deficient practice placed the resident at risk for unnecessary medications and related side effects. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia with agitation (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · 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 70 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 5 had an approved diagnosis or a physician-documented rationale which included risks versus benefits for R5's use of Rexaulti (an antipsychotic class of medication used to treat mental conditions which cause a break from reality), and R 36's Seroquel (an antipsychotic medication)s used to treat major mental conditions which cause a break from reality). The facility further failed to ensure R20 had a 14-day stop date for the use of Ativan (an antianxiety medication). This deficient practice placed the residents at risk for unnecessary medications and related complications. Findings included: - The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia with agitation (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 70 residents. Based on observation, interview, and record review, the facility failed to dispose of expired medications in a timely manner. This deficient practice placed residents at risk to receive ineffective medication. Findings included: - On 01/28/25 at 01:35 PM, observation in the facility's only medication room revealed a bottle of 325 milligrams (MG) aspirin tablets with an expiration date of 08/2024 and a bottle of GeriMox (antacid medication), expired 11/2024. On 01/28/25 at 01:35 PM, Licensed Nurse (LN) J verified the expired drugs should have been disposed of. The facility's Medication Storage in the Facility policy, dated April 2020, stated drugs dispensed in the manufacturer's original container would be labeled with the manufacturer's expiration date. All expired medication would be removed from the active supply and destroyed in the facility. No expired medications would be administered to a resident. The facility failed to dispose of expired medications in a timely manner. This deficient practice placed residents at risk to receive…

    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 · F2023-03-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 57 residents. The facility had one main kitchen where food was stored and prepared serving one dining room. Based on observation, interview, and record review the facility failed to properly store food in the main kitchen refrigerators and freezers due to boxes placed directly on the floor and foods left uncovered; failed to discard expired foods and failed to store opened food products in accordance with professional standards for food service safety, to prevent food borne illness to the residents. Findings included: - During the brief initial tour of the kitchen, on 03/22/23 at 07:46 AM, the following items were discovered: 1. The walk-in refrigerator had a sheet pan with shredded potatoes spread on it and a sheet pan with five cups of fruit on it open to air without a cover on either of them. 2. The walk-on freezer had approximately 10 various food boxes sitting directly on the floor with 30 boxes stacked on them. 3. The walk-in refrigerator had a box of lettuce open to air and wilted and not dated. 4. The bread rack contained one loaf of bread…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-27 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility census totaled 57 residents residing on four halls in the facility. Based on observation, record review, and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment by the failure to repair walls where they were scuffed into the dry wall and paint missing on three out of four halls and elevated noise levels on the two south halls that were unacceptable to residents voicing complaints about noise levels. Findings included: - Observation, on 03/22/23 10:21 AM, revealed large gouges in a wall by the head of the bed in a room on the 100 hall. Several areas where walls have been hit and paint was gone noted on the south halls. On 03/28/23 at 11:00 AM, a tour of the facility with Maintenance Staff U revealed several areas on the south two halls where paint and plaster were scuffed off on the walls. The wall in a resident room on a north hall revealed a large deep gouge approximately 10 inches in diameter on the wall by the head of the bed. The area had paint and plaster missing. Interview, on 03/22/23 at 11:30 AM, with Maintenance 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Ecited before2023-03-27 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R25's pertinent diagnoses from the Electronic Health Record (EHR) documented schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Review of 25's annual Minimum Data Set (MDS), dated [DATE] documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. The resident received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication and an antidepressant medication seven out of seven days in the look-back period. Review of 25's quarterly MDS, dated [DATE] documented a BIMS of 13, indicating intact cognition. The resident received antipsychotic and antidepressant medications seven out of seven…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-27 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 57 residents with 17 selected for review. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident (R)33 and R14 when certified nurse aide (CNA) P, and Licensed Nurse (LN)H entered R33's room without knocking. Findings included: - On 03/22/23 at 09:00 AM, during interview with R33, a CNA P opened the door and entered the resident's room without knocking or announcing herself then promptly left. On 03/22/23 at 04:45 PM, R14, a resident with post-traumatic stress disorder (PTSD - psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture) stated that approximately three to four months prior, a staff member walked into her room without knocking or announcing themselves. R14 revealed that she was changing her clothes at the time, and the incident caused her emotional distress due to the intrusion into 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-27 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 57 residents with 17 selected for review, including two residents for participation in care planning. Based on interview and record review, the facility failed to include Residents (R)14 and 49 in their care planning. Findings included: - On 03/22/23 at 10:02 AM, R14 stated that she was unable to recall having been to a care plan meeting in a long time but was unable to specify how long. On 03/22/23 at 11:42 AM, R49 stated that he did not recall ever having attended a care plan meeting since his admission to the facility in 08/2022. On 03/23/23 at 03:52 PM, Certified Nurse Aide (CNA) M revealed care plan meetings happened on first shift, and she had never been invited to attend. On 03/23/23 at 04:18 PM, Licensed Nurse (LN) I revealed care plan meetings happened every three months. On 03/27/23 at 12:06 PM, Social Services X revealed she was only employed in her current role for a few months. She stated prior to her employment, care plan meetings had not been done for reasons that were unknown to her. She was able to produce an attendance roster for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-27 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 57 residents which included 17 selected for review. Based on interview and record review, the facility failed to accurately complete a comprehensive assessment on resident (R)33, related to the resident's cognition. Findings include: - Review of R33's diagnoses from the Electronic Health Record (EHR) documented history of falls, osteoporosis (a degenerative age-related condition of the bones which causes them to be brittle and susceptible to breaking) and fracture of upper end of the resident's [left] humerus (a broken upper arm bone). Review of the 09/16/22 admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of not assessed indicating that R33's cognition was not assessed. Documented a total severity score of not assessed indicating that R33 was not assessed for depression symptoms. The Care area Assessment dated 09/16/22, lacked documentation related to the resident's cognitive or mental status. The care plan, dated 03/23/23, lacked guidance related to the resident's cognition or mental status. On 03/28/23 at…

    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 · D2023-03-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 57 residents with 17 included in the sample. Based on interview, record review the facility failed to revise the care plans for two residents by the failure to care plan injury and treatment to Resident (R11) shoulder injury and R 165's facility acquired pressure ulcer. Findings included: - R 11's signed physician orders dated 03/21/23 revealed the following diagnoses: hemiplegia and hemiparesis (paralyzed on one side of body) following 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) affecting right dominant side and muscle weakness. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident required extensive assistance with transfers and toilet use. The resident used a walker or wheelchair for locomotion. The resident had impaired range of motion in his upper and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 57 residents, with 17 sampled, including two residents sampled for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide care consistent with standard of practice for Resident (R) 165 and R 163 to maintain good grooming and personal hygiene. - The 03/23/23 Electronic Health Record (EHR) documented R 163 had the following diagnosis of orthopedic aftercare (aftercare following a joint replacement). The 02/14/23 admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 13, indicating intact cognition. The assessment noted that it was very important for R 163 to choose what to wear and to choose between a shower or a bath. R 163 required extensive assistance of one staff for all ADL. R 163 was totally dependent on one staff for bathing. The 02/14/23 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R 163 needed extensive assistance with all ADL. The 03/03/23 Care Plan lacked documentation regarding bathing preferences for R 163. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 57 residents, with 17 sampled, including two residents sampled for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failure to perform skin assessments to identify a pressure area for Resident (R) 165, allowing an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured) pressure ulcer to develop. Findings included: - The 03/23/23 Electronic Health Record (EHR) documented R165 had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 57 residents with 17 selected for review which included one resident for accident hazards. Based on observation, interview and record review, the facility failed to provide a safe environment when staff placed a call light out of the reach of Resident (R)33. Findings include: - R33's diagnoses from the Electronic Health Record (EHR) documented history of falls, osteoporosis (a degenerative age-related condition of the bones which causes them to be brittle and susceptible to breaking) and a fracture of the upper end of (left) humerus (a broken upper arm bone). Review of R33's admission Minimum Data Set (MDS), dated [DATE] lacked complete documentation for cognition (brief interview for mental status). Documented that the resident required limited assistance of one to two staff for all ADLs (activities of daily living). Further documented one fall without injury prior to admission. Review of R33's quarterly MDS, dated [DATE], documented a brief interview for mental status (BIMS)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-27 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R 15's signed physician orders dated 03/01/23 revealed the following diagnoses- hypertension (elevated blood pressure) atherosclerotic heart disease (where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall.), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. The resident had no behaviors and received antipsychotic and antidepressant medications. The Care Area Assessment (CAA) dated 10/07/22 revealed: Cognitive Loss CAA triggered secondary to orientation, memory, and recall deficits noted during BIMS interview. Contributing factors include dementia. Risk factors include self-care deficits, falls and injuries, incontinence, decreased socialization, skin breakdown, weight loss, and fluid imbalance. The Care Plan dated 08/19/19 revealed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 57 residents with 17 residents selected for review, that included six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure Resident (R)25 and R14 were monitored for side effects of extrapyramidal (abnormal involuntary body movements caused by medications) symptoms due to antipsychotic (a class of medication used to treat psychosis and other mental emotional conditions) medication use and for R29 when the facility failed to have a stop date on an as needed (PRN) psychotropic (classes of medications that affect the mind, mood or mental processes) medication. Findings included: - R 25's pertinent diagnoses from the Electronic Health Record (EHR) documented schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and major depressive disorder (a serious…

    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 · Ecited before2021-09-27 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 47 residents. Based on observation, interview, and record review the facility failed to provide maintenance services to maintain a sanitary, orderly, and comfortable interior which included three of four hallways and two of 39 resident rooms. Findings included: - Environmental observations on survey from 09/21/21 through 09/27/21 revealed the following concerns: 1. Northeast hallway included: a. Hallway had dings and gouges in the walls that looked like maintenance had started to repair but still needed to be repainted. b. A residnet room had pockmarks on the wall next to the bed. c. Another resident room had numerous circular black marks on the wall behind the head of the bed. 2. Northwest hallway included: a. The housekeeping closet between resident rooms had damage from approximately 30 inches up from the bottom of the door where the wood was scratched and gouged. b. The Resident Bathing room door, displayed scratched and gouge markings, from the bottom of the door up to approximately 30 inches. c. The Women's Bathroom door had scratches along the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-09-27 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 47 residents with 12 in the sample and five residents reviewed for unnecessary medications. Based on interview, observation and record review the facility failed to ensure the consultant pharmacist identify and report an irregularity concerning Resident (R)15 use of as needed (PRN) Ativan (antianxiety medication). The facility also failed to follow up on recommendations from the consultant pharmacist concerning Gradual Dose Reductions (GDR) for R15's use of Trazadone (antidepressant medication), R33's use of Celexa (antidepressant medication), R38's use of Mirtazapine, Zoloft and Trazadone (antidepressant medications), discontinuation or documentation of an end date for R34's use of Doxycycline (antibiotic medication), the recommendation to not administer aspirin (Nonsteroidal Anti-Inflammatory Drugs (NSAID, medication that reduces pain, decreases fever, prevents blood clots, and in higher doses, decreases inflammation) with Xarelto, an anticoagulant medication (chemical substances…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-27 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 47 residents with 12 sampled including two for indwelling urinary catheters (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review the facility failed to promote dignity when staff failed to provide a dignity bags for the indwelling urinary catheter drainage bags for Resident (R) 44 and R148. Findings included: - R44's Physician Order Sheet dated 09/21/21 revealed the following diagnoses: neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and presence of urogenital implant (injections of material into the urethra to help control urine leakage/urinary incontinence). The 08/08/21 Annual Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. R44 had an indwelling urinary catheter. The 08/08/21 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R44 had an indwelling urinary catheter in place and required staff assistance…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-09-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 47 residents with 12 sampled, which included two for respiratory care. Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for Resident (R) 33 by the failure of staff to change oxygen tubing and store oxygen tubing sanitarily. The facility further failed to store oxygen tubing sanitarily for R15. Findings included: - R33's Electronic Health Record (EHR) documented diagnoses of chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The 08/17/21 Significant Change Minimum Data Set (MDS) revealed a staff assessment indicated R33 had both long and short-term memory problems and severely impaired cognition. R33 did not use oxygen. The 09/01/21 Care Plan documented R33 required oxygen via…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-27 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R16's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 08/03/21 documented type two diabetes mellitus (DM, when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and peripheral vascular disease (PVD, abnormal condition affecting the blood vessels). The 07/21/21admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R16 received anticoagulant medication six times in the seven-day look back period. The 08/03/21 Care Plan for R16 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order on 07/15/21 for R16 for Xarelto (blood thinner) 20 milligrams (mg) daily and an order on 07/16/21 for aspirin 81 mg daily. Review of the monthly Pharmacy Medication Record Review (MRR) for July and August 2021 revealed a recommendation for the prescriber of R16, to review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 47 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow up on the consultant pharmacists' recommendations for a gradual dose reduction (GDR) for the ordered Citalopram (antidepressant medication), for Resident (R)33, for the recommended stop date for the as needed (PRN) Ativan (antianxiety medication) ordered for R15, and for the GDRs for Trazadone, Mirtazapine, and Zoloft (antidepressant medications), received by R38. Findings included: - R33's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 09/01/21 documented dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). The 08/17/21 Significant Change Minimum Data Set (MDS) documented per staff R33 had both long and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-03-27 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 57 residents. Based on observation, interview, and record review, the facility failed to post the daily staffing document in a conspicuous place readily accessible to residents and visitors. In addition, the facility failed to ensure the daily staff posting included the actual hours worked by the nursing staff as required as well as the facility's name. Findings included: - On 03/28/23 at 11:30 AM, Administrative Nurse D revealed daily staffing document posted on a clipboard that hung backwards on the side of shelving behind the nursing station, which was inconspicuous and not accessible to residents or visitors. Review of the daily staff posting documents from 03/21/23 to 03/28/23 revealed a lack of documentation of actual hours worked or identification with the facility's name. On 03/28/23 at 11:30 AM, Administrative Nurse D revealed Administrative Nurse F was responsible for daily staff posting. On 03/28/23 at 11:40 AM, Administrative Nurse F revealed she was unaware of the required elements of daily staffing document. The facility failed to…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$8,376 in federal fines across 1 penalty.

  • $8,376 — penalty dated 2024-09-05

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

Part of a chain

This home belongs to DIVERSICARE HEALTHCARE — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.6+1.4 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 4 of 53.5+0.5 vs chain
The other 43 homes this chain runs (chain average 2.6★, per CMS)
1 of 5Diversicare Of BessemerBessemer, AL 1 of 5Diversicare Of HaysvilleHaysville, KS 1 of 5Diversicare Of MeridianMeridian, MS 1 of 5Diversicare Of Oak RidgeOak Ridge, TN 1 of 5Diversicare Of OxfordOxford, AL 1 of 5Diversicare Of RipleyRipley, MS 1 of 5Diversicare Of SedgwickSedgwick, KS 1 of 5Diversicare Of SouthavenSouthaven, MS 1 of 5Lampasas Nursing and Rehabilitation CenterLampasas, TX 1 of 5Windsor HouseHuntsville, AL 2 of 5Diversicare Of AmoryAmory, MS 2 of 5Diversicare Of ArabArab, AL 2 of 5Diversicare Of BatesvilleBatesville, MS 2 of 5Diversicare Of BoazBoaz, AL 2 of 5Diversicare Of BrookhavenBrookhaven, MS 2 of 5Diversicare Of ChanuteChanute, KS 2 of 5Diversicare Of Council GroveCouncil Grove, KS 2 of 5Diversicare Of EuporaEupora, MS 2 of 5Diversicare Of FoleyFoley, AL 2 of 5Diversicare Of MontgomeryMontgomery, AL 2 of 5Diversicare Of Moss PointMoss Point, MS 2 of 5Diversicare Of Pell CityPell City, AL 2 of 5Diversicare Of TupeloTupelo, MS 2 of 5St Martin's In The PinesIrondale, AL 3 of 5Chisolm Trail Nursing and Rehabilitation CenterLockhart, TX 3 of 5Diversicare Of Copper BasinCopperhill, TN 3 of 5Diversicare Of LulingLuling, TX 3 of 5Diversicare Of OneontaOneonta, AL 3 of 5Diversicare Of QuitmanQuitman, MS 3 of 5Diversicare Of RiverchaseBirmingham, AL 3 of 5Diversicare Of ShelbyShelby, MS 3 of 5Park PlaceSelma, AL 3 of 5Yorktown Nursing and Rehabilitation CenterYorktown, TX 4 of 5Baron House Of HueytownHueytown, AL 4 of 5Diversicare Of Big SpringsHuntsville, AL 4 of 5Diversicare Of LanettLanett, AL 4 of 5Diversicare Of WinfieldWinfield, AL 4 of 5Hartford Health CareHartford, AL 5 of 5Diversicare Of GreensboroGreensboro, AL 5 of 5Diversicare Of LarnedLarned, KS

Showing 40 of 43; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
DIVERSICARE KANSAS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/17/2014
ADVOCAT FINANCE, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/29/2013
DAC NEWCORP INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/04/2022
DIVERSICARE HOLDING COMPANY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/29/2013
DIVERSICARE MANAGEMENT SERVICES LP.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/10/1996
JOHNSON, RENEEIndividualW-2 MANAGING EMPLOYEE; ADP OF THE SNFsince 03/27/2023
KELLMAN, FRANKLINIndividualCORPORATE DIRECTORsince 09/13/2024
KOHN, BRIANIndividualCORPORATE DIRECTORsince 11/19/2021
RATNER, ERANIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 09/13/2024
BODIE, REBECCAIndividualCORPORATE OFFICERsince 03/02/2020
NEE, STEPHENIndividualCORPORATE OFFICERsince 02/20/2023
WEISHAAR, MATTHEWIndividualCORPORATE OFFICERsince 12/01/2003
DMS GP LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 04/04/2022
DIVERSICARE HEALTHCARE SERVICES LLCOrganizationLIMITED PARTNERSHIP INTERESTsince 04/04/2022

CMS files one row per role, so the 16 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$6.9M
Net patient revenuemost recent cost report
+7.7%
Operating marginrevenue minus expenses
$860K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 12%Other / private 22%

This home reported $860K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$291per resident / day
operating cost
$8,845per month
≈ monthly operating cost
$315per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.

Typical monthly cost in Kansas
$8,669/mo
Nursing home (semi-private)
$9,064/mo
Nursing home (private)
$5,975/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175114. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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