Good Samaritan - Hutchinson Village
810 E 30th Avenue, Hutchinson, KS 67502 · Non profit - Corporation · 65 certified beds · (620) 663-1189 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
- it has 1 actual-harm citation
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.4% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.9% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.4% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.6% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.3% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.3% | 16.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 19.0% | 23.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.8% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 4.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.6% | 18.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.1% | 73.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.9% | 22.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.4% | 11.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.39 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.61 | 2.13 | 1.80 | worse |
‡ 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.
45.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.8% 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 42 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 0.12 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% 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.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 45.7%CMS range 35.5–58.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 8.1–16.8 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 54.8% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 47.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.4% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 96.5% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 4.4–13.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 65 beds and averages 52.3 residents a day — about 80% occupied, or roughly 13 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 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 2.98 hrs/resident/day on weekends vs 3.74 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.69 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · G2023-08-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 51 residents residing on two halls, North and South. The South Unit had 14 cognitively impaired residents and one Resident, (R) 1, who stated a Certified Nurse Aide (CNA) on duty was rough with her. Based on observation, interview, and record review, the facility failed to provide a safe environment for 14 residents when CNA E reported to work tearful and stated she did not want to be there, which led to the CNA being rough/loud with R1, causing bruises/scratches during a transfer, and making the resident attend a meal when she stated she did not feel well. This put the 14 residents on the South Unit at risk for abuse. Findings included: - Resident (R) 1's signed physician orders dated 11/10/22 revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-03 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 51 residents. The sample included 14 residents. Based on record review and interview, the facility failed to ensure the required annual performance reviews were completed at least once every 12 months for one Certified Medication Aide (CMA) and three Certified Nurse Aides (CNA).Findings included:- Review of the requested facility performance reviews noted the following staff lacked an annual review:CMA T's, hired on 01/11/08, last performance evaluation was completed on 05/31/24. The facility lacked evidence that a performance review was completed in the last 12 calendar months upon request. CNA NN's, hired on 12/19/14, last performance evaluation was completed on 05/31/24. The facility lacked evidence that a performance review was completed for CNA NN.CNA O was hired on 07/26/24. The facility lacked evidence that a performance review was completed for CNA O.CNA MM was hired on 11/19/24. The facility lacked evidence that a performance evaluation was completed for CNA MM.On 12/02/25 at 12:35 PM, CNA O stated she had not had a performance evaluation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 51 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage. This placed the 51 residents at risk for food-borne illness. Findings included: - On 12/01/25 at 08:20 AM, the walk-in refrigerator and freezer did not have thermometers inside.The November 2025 Temperature Log directions directed staff to obtain temperatures in the morning and afternoon. The log lacked recorded temperatures for both the morning and the afternoon on 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/05/25, 11/09/25, 11/13/25, 11/14/25, 11/22/25, and 11/27/25. The log documented the one temperature on 11/20/25 in the afternoon temperature, but lacked a morning temperature. On 12/02/25 at 11:40 AM, observation used dish rags sat next to clean pitchers in the dishwasher room. The magnetic knife holder above the make table had dried food on it. The toaster had a copious amount of dried bread particles on it and on the controls. On 12/01/25 at 08:20 AM, Dietary Staff BB verified the lack of thermometers in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of 51 residents. Based on observation, interview, and record review, the facility failed to remove or dispose of expired medication in the facility's north medication room. Findings included: - On 12/01/25 at 03:07 PM, inspection of the facility's north medication room revealed:Three unopened bottles of magnesium chloride pills, with an expiration date of 10/2025. A box of 100 bisacodyl suppositories, with an expiration date of 09/2025. On 12/01/25 at 03:07 PM, Administrative Nurse E verified the expiration dates and stated staff were to remove expired medications from service. The facility's Medication Acquisition, Receiving, Dispensing and Storage policy, dated 03/04/25, stated nursing staff would routinely check for expired medications, and necessary disposal would be done in accordance with state/pharmacy regulations.
- Potential for harm · D2025-12-03 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 51 residents. The sample included 14 residents with Resident (R) 6 reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a collaboration of care between R6's hospice provider and the facility, which included the information on what hospice services would be provided to the residents, as well as how often hospice staff would visit the facility.Findings included:- R6's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (HTN- elevated blood pressure), and chronic kidney disease (CKD- a long-term condition where the kidneys become damaged and cannot filter blood well, causing waste buildup).R6's Significant Change Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R6 required partial to moderate assistance from staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 53 residents. Based on observation, record review and interview, the facility failed to follow proper food handling practices to prevent the outbreak of foodborne illness. Findings included: - During the initial tour of the kitchen on 11/13/ at 08:30 AM, the refrigerator had the following areas of concerns: 1. One open bag of hotdogs, that lacked an opened date 2. One bag of turkey lunch meat that lacked an opened date and lack a use by date. On 11/13/23 at 08:30 AM, observation of the dry storage area revealed three bags of hot dog buns with a used by date of 10/30/23. In addition, there was one dented can of sliced beets and one dented can of fancy sauerkraut. Interview on 11/14/23 at 11:47 AM, Dietary staff I reported when the facility received a can with a dent from the vendors, staff need to take a picture of it and send it to the certified dietary manager, so the facility could get credit for the dented can, or just throw the dented cans of food in the trash. Food, including the breads should not be used if the date is past the use by date.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-20 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 reported a census of 53 resident with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, by not having a dignity bag for the indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) collection bag. Findings included: - The Physician's Orders dated 10/10/23 revealed R4 had a diagnosis of urinary retention (the lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R4 had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 10/12/23, revealed R4 arrived at the facility from the hospital with an indwelling catheter. The Care Plans dated 10/12/23 documented R4 would remain free from catheter-related trauma through review date. Monitor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-20 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 residents which included 12 residents sampled for reviewed for transmission of Minimum Data Set, (MDS) assessments. Based on interview and record review, the facility failed to electronically transmit Resident (R)51's Discharge Return not Anticipated MDS, tracking no later than 14 days after the assessment Reference date (ARD) of 08/23/23, and/or seven days after the completion date of the MDS as required. Findings included: - On 11/20/23 at 12:30 PM, review of Resident (R)51's Discharge Return not Anticipated Minimum Data Set' (MDS), dated [DATE], revealed the MDS had not been electronically transmitted to Centers for Medicare and Medicaid Services (CMS) after the assessment Reference date (ARD) of 08/23/23, and/or seven days after the completion date of the MDS as required. On 11/20/23 at 12:50 PM, Administrative Nurse Q confirmed the facility failed to electronically submit the MDS as noted above. She reported a corporate nurse completed the assessment and she was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 residents. The sample of 12 residents included one resident sampled for personal hygiene related to bathing. Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good personal hygiene for Resident (R)24, related to bathing and hair care. Findings included: - Review of Resident (R) 24's undated Physician's Orders, documentation included diagnoses of morbid (severe) obesity, communication deficit, weakness, and dementia (progressive mental disorder characterized by failing memory). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Staff reported she preferred a tub bath. She required extensive assistance of staff for bed mobility, personal hygiene, and was totally dependent on staff for transfers, locomotion, toilet use, and one staff assist with bathing. The resident was always incontinent of bowel and bladder. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 53 residents with 12 residents included in the sample, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment by failing to implement interventions prevent Resident (R) 106, with moderately impaired cognition, from having repeated falls. Findings included: - R106's signed Physician Orders dated 10/31/23 revealed the following diagnoses: peripheral vascular disease (PVD is an abnormal condition affecting the blood vessels), atrial fibrillation (rapid irregular heart rate), bradycardia (slow heart rate), shortness of breath, unsteadiness on feet, chronic respiratory failure with hypoxia (inadequate supply of oxygen). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The resident was occasionally incontinent of urine and continent of bowel. The resident had no complaints of pain. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 53 with 12 residents in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow recommendation of the pharmacist for Resident (R)17, related to Abnormal Involuntary Movement scale (AIMS- a clinician-rated scale to assess severity of dyskinesias [the inability to execute voluntary movements]) testing and on R6 and R24 regarding as needed (PRN) lorazepam (a medication used for severe agitation) to obtain a new prescription every 14 days. Findings include: - Review of the R17's signed Physician Orders dated 09/11/23, revealed the diagnosis of unspecified dementia moderated without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion). Review of the Discharge Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) revealed a score of staff assessment for mental status with memory problems. R17 received seven days…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · Dcited before2023-11-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 53 residents with 12 residents included in the sample, including five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for Residents (R6 and R24). Findings included: - R6's signed physician orders dated 10/31/23 revealed the following diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating 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.
- Potential for harm · D2023-11-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 reported a census of 53 resident with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program, related to one resident, Resident (R) 4, related to urinary catheter care and placement, to help prevent contamination and the spread of infection. Findings included: - The Physician's Orders dated 10/10/23 revealed R4 had the following diagnosis of urinary retention (the lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R4 had a indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Care Area Assessment (CAA) dated 10/12/23 revealed R4 arrived at the facility from the hospital with the indwelling catheter. The Care Plans dated 10/12/23, revealed urinary incontinence, R4 will remain free from catheter-related…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-01-13 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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 50 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow consultant pharmacist recommendations to add Not to Exceed (NTE) cautions to Resident (R)16 and R17's orders for acetaminophen (medication used to treat minor pain and fever) to reduce the potential for liver damage, failed to add manufacturer's instructions for administration of Voltaren (topical anti-inflammatory gel used for pain relief) for R16, failed to follow recommendations to discontinue the use of as needed (PRN) Alprazolam (sedative medication) for R29, and failed to respond to the recommendation to attempt a Gradual Dose Reduction (GDR) of Mirtazapine (an antidepressant) and Seroquel (an antipsychotic) for R28. Findings included: - Resident (R) 16's Electronic Health Record (EHR) under the Medical Diagnosis tab revealed a diagnosis of pain. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-13 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
The facility census totaled 50 residents with 12 included in the sample. Based on interview and record review the facility failed to ensure one of five Certified Nurse Aide's (CNA) 12- hour annual mandatory in-service training included dementia training. Findings included: - On 01/12/22, the surveyor provided Administrative Staff A a list of five CNAs employed by the facility in excess of 12 months requesting documentation of the annual mandatory in-service trainings. Four of the five staff had the required education; however, CNA M lacked record of completed dementia training in the last 12 months from hire date. On 01/12/22 Administrative Staff A reported she could not find evidence of dementia training for CNA M. The 10/15/19 facility policy Competency and Mandatory Education Requirements revealed employees were responsible to attain and maintain competency and complete mandatory education required within their specific job description. The facility failed to ensure one of five CNA's 12-hour annual mandatory in-service training included the required dementia training.
- Potential for harm · Dcited before2022-01-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R28's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/12/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 11/28/21 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R28 received antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 11/28/21 Psychotropic Drug Use Care Area Assessment (CAA) documented R28 had a history of depression with mood/behavior. R28 received scheduled Seroquel (antipsychotic medication), mirtazapine (antidepressant medication), and Ativan (antianxiety medication). The 11/01/21 Quarterly MDS documented R28 received an antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 91 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 91; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANFORD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/2019 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/2019 |
| BROWN, GEORGE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| DYKHOUSE, DANA | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| GASSEN, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 05/30/2024 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| HERSETH SANDLIN, STEPHANIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| MCCAUSLAND, MAUREEN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| SCHIEFFER, KEVIN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| SHULKIN, DAVID | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 05/30/2024 |
| WENZEL, THOMAS | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 01/01/2025 |
| FLUIT, JOEL | Individual | CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 03/16/2026 |
| MIDDLETON, AIMEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/27/2022 |
| OLSON, NICHOLAS | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/08/2024 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2022 |
| AMUNDSON, ZACHARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/16/2023 |
| HART, GERI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/13/2015 |
| MORRISON, TONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
| SANDGREN, DEEANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2023 |
| DTN STAFFING INC | Organization | ADP OF THE SNF | — | since 08/02/2024 |
| FOCUSONE SOLUTIONS | Organization | ADP OF THE SNF | — | since 03/04/2024 |
| GRAPE TREE MEDICAL STAFFING LLC | Organization | ADP OF THE SNF | — | since 04/13/2018 |
| OMNICARE LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
CMS files one row per role, so the 56 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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
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
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.
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 175260. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-03, 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.