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Medicalodges Iola

600 E Garfield Street, Iola, KS 66749 · For profit - Limited Liability company · 45 certified beds · (620) 365-3183 Medicare & Medicaid certified

Call the home — (620) 365-3183 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0609, F0610) — most recent May 20245 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$42,224 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0609, F0610) — most recent May 2024
  • inspectors recorded 5 serious findings 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 (41) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $42,224 in federal fines (most recent 2024-05-06)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
826 E Madison Ave · (620) 365-6933 · Call to confirm hours
Pharmacy
2051 N State St · (620) 380-6400 · Call to confirm hours
Grocery
101 S 1st St · (620) 228-5570 · Call to confirm hours
Park
500 E Garfield St · (620) 365-4930 · 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 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 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased17.3%17.9%15.4%worse
Long-stay residents who lose too much weight4.7%4.9%5.4%better
Long-stay residents with a catheter left in their bladder1.3%1.6%0.9%worse
Long-stay residents with a urinary tract infection10.9%2.9%2.0%worse
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 injury5.2%4.3%3.3%worse
Long-stay residents whose ability to walk worsened28.9%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication29.6%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine97.1%95.5%95.3%typical
Long-stay residents with pressure ulcers2.2%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control32.1%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table27.2%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication5.6%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine70.0%73.8%79.4%worse
Short-stay residents rehospitalized after admission18.9%22.4%22.6%better
Short-stay residents with an outpatient ER visit19.5%11.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.401.801.67better
Long-stay outpatient ER visits per 1,000 resident days4.352.131.80worse

* 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.

38.5% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

38.5%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
87.5%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 87.5% 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 24 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNF38.5%CMS range 26.7–52.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 6.5–14.810.7%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 discharge87.5%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 discharge66.7%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 discharge70.8%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 identified80.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 2.8–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

0.78
RN hours/ resident / day
0.58
LPN hours/ resident / day
2.85
Aide hours/ resident / day
4.20
Total nurse hours/ resident / day
0.67
RN hoursweekends
51.1%
Total nursing turnover
70.0%
RN turnover

How full it usually is: this home is certified for 45 beds and averages 41.5 residents a day — about 92% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.85 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.52 hrs/resident/day on weekends vs 4.48 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.82 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

12
deficiencies at the latest standard inspection (2025-07-23)
11
at the previous standard inspection (2024-01-25)

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

Inspection deficiencies

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

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.

41 citations, most serious first. The 15 most serious are shown; the remaining 26 are one tap away and print in full.

  • Immediate jeopardy · J2024-05-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 reported a census of 36 residents with four residents sampled. Based on observation, record review, and interview, the facility failed to prevent the physical abuse and neglect of R2. On 03/21/24, R2 reported Certified Nurse Aide (CNA) M was rough with her when assisting her to bed around 06:30 PM to 07:00 PM. R2 stated CNA M threw her into her bed by having a hold of her legs and swung her on the bed, while in the lift sling, during the transfer from the wheelchair to her bed. Afterwards, R2 experienced dizziness, nausea, and difficulty breathing due lying flat as the head of the bed was flat. R2 activated her call light and when nobody responded to the call light, R2 started yelling out. When CNA M responded to R2, she did so by yelling at R2 from the hallway saying R2 was not the only resident left to take care of. R2's bed remained flat and R2 lacked application of her supplemental oxygen for 3 to 3.5 hours, until CNA N arrived for the 10:00 PM shift. While rounding, R2 hollered out CNA N's name…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2024-05-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with four residents sampled. Based on observation, record review, and interview, the facility failed to report abuse and neglect of R2 immediately on 03/21/22 at 10:10 PM. On 03/21/24, R2 reported Certified Nurse Aide (CNA) M was rough with her when assisting her to bed around 06:30 PM to 07:00 PM. R2 stated CNA M threw her into her bed by having a hold of her legs and swung her on the bed, while in the lift sling, during the transfer from the wheelchair to her bed. Afterwards, R2 experienced dizziness, nausea, and difficulty breathing due to lying flat as the head of the bed was flat. R2 activated her call light and when nobody responded to the call light, R2 started yelling out. When CNA M responded to R2, she did so by yelling at R2 from the hallway saying R2 was not the only resident left to take care of. R2's bed remained flat and R2 lacked application of her supplemental oxygen for 3 to 3.5 hours, until CNA N arrived for the 10:00 PM shift. While rounding, R2…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2024-05-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 36 residents with four residents sampled. Based on observation, record review, and interview, the facility failed to protect Resident (R) 2 from further abuse and neglect. On 03/21/22 at 10:10 PM when staff failed to notify the administrator immediately of an allegation of abuse and neglect. R2 reported Certified Nurse Aide (CNA) M was rough with her when assisting her to bed around 06:30 PM to 07:00 PM. R2 stated CNA M threw her into her bed by having a hold of her legs and swung her on the bed, while in the lift sling, during the transfer from the wheelchair to her bed. Afterwards, R2 experienced dizziness, nausea, and difficulty breathing due to lying flat as the head of the bed was flat. R2 activated her call light and when nobody responded to the call light, R2 started yelling out. When CNA M responded to R2, she did so by yelling at R2 from the hallway saying R2 was not the only resident left to take care of. R2's bed remained flat and R2 lacked application of her…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Jcited before2024-05-06 · 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 reported a census of 36 residents, with four residents sampled, including three residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment, as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)1. On 04/27/24 during the 05:45 PM to 06:00 AM shift, staff deactivated an exit door alarm on a hallway R1 did not reside on due to a storm causing the alarm to sound. On 04/28/24 at 03:57 PM, R1 attempted to exit a hallway door on the side of the facility the resident resided on, and staff redirected R1. On 04/28/24 at 03:59 PM, R1 sat in a chair in the activity area next to the nurse's station of the area of the facility he resided on. Shortly after, R1 exited the hallway door where the alarm had been deactivated. The facility 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Jcited before2023-12-20 · 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 36 residents with one resident reviewed, Resident (R)1, for accident hazards. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe environment as free of accidents as possible, when Social Service Staff X propelled R1 in her wheelchair backwards out of the facility's transport van, but failed to ensure the mechanical lift platform was in the proper up position. R1 flipped backwards in her wheelchair out of the van. The resident stated she could not breath as she was upside down having fell approximately two feet from the van door to the lift platform which was at ground level. R1 struck her shoulder and back on the lowered platform and her head on the ground. R1 required emergency medical transport for evaluation and treatment after the fall, where she was diagnosed with a concussion (damage to the brain caused by violent jarring or shaking, such as a blow). R1 had pain following the fall and suffered significant bruising to her…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2025-07-23 · tag F0730 — widespread
    Observe 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 reported a census of 43 residents. Based on interview and record review, the facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) who were employed at the facility for more than 12 months. This placed the residents at risk for decreased quality of care.Findings included:- Review of personnel records on 07/22/25 at 07:25 AM revealed that Certified Medication Aide (CMA) T, CMA U, CNA M, CNA N, and CNA L did not have performance evaluations completed for the last 12 months of full-time employment.During an interview on 07/22/25 at 07:25 AM, Administrative Staff A stated that no performance evaluations were completed for the five CNAs selected for review. Administrative Staff A further stated that she was aware that evaluations should have been completed, but they were not.The facility's Employee Handbook, dated 05/24/20, documented that full and part-time employees should receive formal, written evaluations. Supervisors, administrators/managers/directors are requested to conduct annual performance evaluations. It further…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-23 · 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 43 residents with two kitchens. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the spread of food-borne illness to the residents of the facility. This placed the residents at risk for food-borne illness.Findings included:- Initial tour of the kitchen on 07/021/25 at 08:40 AM with Dietary Manager BB revealed the following areas of concern:The top of the automated dishwasher had dried food debris on it.The ice maker had food particles on the top and sides of it, and food was stored on top of it in storage bags.The kitchen area had multiple fans placed throughout the kitchen., The fans were dirty and dusty and blowing into the food preparation area and the dish cleaning area.There were numerous food items and trash on the floor.The trash cans in the food preparation area were visibly dirty on the outside.The counter where the coffee pot sat had spilled coffee on it.The floors were sticky and slick.Observed on 07/21/25 at 03:50 PM, seven plastic cutting…

    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 · F2025-07-23 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 43 residents. Based on interview and record review the facility failed to ensure the designated Infection Preventionist (IP) was trained and certified in infection prevention and control. This failure placed all 43 residents at increased risk for infectious disease. Findings included: - During an interview on 07/23/25 at 12:11 PM, Administrative Staff A revealed the facility did not have a certified IP. Administrative Staff A stated the previous certified IP left 06/01/25, and the current IP is not certified. During an interview on 07/22/25 at 03:10 PM, Administrative Nurse C, the facility-identified IP, confirmed he was not certified in infection control. The facility's Infection Control Surveillance policy dated 11/2023 documented that the infection control preventionist is to monitor compliance with state and federal regulatory standards as they pertain to infection prevention and control.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-07-23 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 43 residents. Based on interviews and record review, the facility failed to ensure the mandatory 12 hours of education were completed for Certified Nurse Aides (CNA) as required. This placed the residents at risk for decreased quality of care.Findings included:- Review of Certified Medication Aide (CMA) U's personnel and training records revealed CMA U had not completed any of the mandatory 12 hours of education in the last 12 months.On 07/23/05 at 08:46 AM, Administrative Staff A reported that she had performed her own investigation and discovered that CMA U had not completed the mandatory 12 hours of education. Administrative Staff A also reported that the facility did not have a policy related to education, and said the facility follows the regulations.On 07/23/25 at 09:00 AM, CMA U verified that she had not completed the mandatory 12 hours of education for the last 12-month period. The facility did not provide a policy.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-23 · tag F0552 — pattern
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 43 residents. The sample included 13 residents, with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure informed consent including purpose, risks versus benefits, and expected therapeutic benefits for the use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), anxiolytic (medication used to treat symptoms of anxiety) and other psychotropic medications (drugs that affect the brain and nervous system to treat mental illnesses)) for Resident (R)14, R6, R42, R17 and R2. This placed the residents at risk for adverse side effects of the medications and uninformed decisions. Findings included:- R14's Electronic Medical Record (EMR) included the following diagnoses: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R14's EMR documented the following physician's orders:Sertraline…

    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 before2025-07-23 · 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 reported a census of 43 residents. The sample included 13 residents. Based on interviews, observation, and record review, the facility failed to ensure a safe, clean home-like environment in all areas of the facility, including the dining area. This deficient practice placed the residents at risk for tripping hazards and decreased comfort.Findings included:- During an observation on 07/21/25 at 09:26 AM, Resident (R) 2's fall mat and room floor had sticky food particles and debris on them. Licensed Nurse (LN) G acknowledged that the mat was filthy and the floor was very sticky and cleaned the mat at that time. During an observation on 07/22/25 at 10:05 AM, the floor area in the dining room had 44 tiles missing; no hazard sign or barrier was blocking the trip hazard.During an observation on 07/22/25 at 10:58 AM, the door on a resident room on the 400-hall displayed bubbling on the surface where the Veneer was separating. The door frames of the doors on the 400-hall had bubbled, chipped, and missing paint.During an observation on 07/22/25 at 11:02 AM, the door frames on…

    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 before2025-07-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 43 residents. The sample included 13 residents. Based on observations, interviews, and record review, the facility failed to maintain an effective infection control program related to the Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). The facility failed to ensure adequate hand hygiene and personal protective equipment (PPE) when caring for residents. Additionally, staff failed to store respiratory equipment in a sanitary manner. This placed the residents at risk for infections.Findings included:- Observation on 07/21/25 at 11:49 AM, Resident (R)'s fall mat next to his bed had cracks and frayed areas exposing the inner foam.Observation on 07/21/25 at 11:52 AM, R7 had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) with the collection bag resting on the floor next to his bed. There was no PPE for EBP located in or around the room, and no signage alerting staff to the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 43 residents; the sample included 13 residents. Based on interviews, observations, and record review, the facility failed to protect the dignity of three residents, Resident (R) 2, when R2 was transported from his room to the shower room via a shower chair only covered with a white sheet with his buttocks exposed. Additionally, staff entered the rooms of R2, R7, and R8 without knocking first and did not identify themselves or await acknowledgment from the resident. These deficient practices placed the residents at risk for negative psychosocial effects related to impaired dignity.Findings included:- During an observation on 07/21/25 at 09:58 AM, Certified Nurse Aide (CNA) O knocked on R8's door once and then entered the room without acknowledgement from R8 while he was being interviewed. R8 stated that staff frequently entered his room without knocking or waiting for permission.During an observation on 07/21/25 at 09:25 AM, R7's door was closed, and CNA O opened the door and entered R7's room without knocking or introducing herself.During an…

    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 · D2025-07-23 · tag F0641 — isolated
    Ensure each resident receives an accurate 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 43 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set for Resident (R) 5 and R14. This placed the resident at risk for impaired care due to unidentified care needs. Findings included:- R5's Electronic Medical Record (EMR) documented a diagnosis of Parkinson’s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dementia (a progressive mental disorder characterized by failing memory and confusion). R5’s 04/23/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, which indicated severe cognitive impairment. R5 had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) and was dependent on staff for assistance. The MDS documented R5 had one non-injury fall. R5’s…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents; the sample included 13 residents. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for Resident (R)6 regarding non-pharmacologic pain interventions and for R42 regarding oxygen use. This placed the residents at risk for impaired care due to uncommunicated care needs.Findings included:- R6's Electronic Medical Record (EMR) revealed a diagnosis of trigeminal neuralgia.R6's Significant Change Minimum Data Set (MDS), dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received scheduled and as-needed (PRN) pain medications and reported she had occasional pain, which rarely affected her day-to-day activities and sleep. The MDS noted R6's worst pain in the past five days was rated at a five on a one to 10 pain scale (one being minimal pain and 10 the worst pain imaginable).The Pain Care Area Assessment (CAA), dated 05/21/25, did…

    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
Show the remaining 26 citations
  • Potential for harm · Dcited before2025-07-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 43 residents. The sample included 13 residents, with one resident reviewed for urinary tract infections. Based on observation, interview, and record review, the facility failed to provide Resident (R) 5, who had an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag), with appropriate treatment and services to care for a catheter and to prevent urinary tract infections (UTI-an infection in any part of the urinary system). This deficient practice placed the resident at risk for UTI and other catheter-related complications.Findings included:- R5's Electronic Medical Record (EMR) documented a diagnosis of UTI, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dementia (a progressive mental disorder characterized by failing memory and confusion).R5's 04/23/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, which indicated…

    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 · D2025-07-23 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents; 13 residents were sampled, including one resident reviewed for pain. Based on observation, interview, and record review, the facility failed to administer pain medications for Resident (R) 6, who had a diagnosis of trigeminal neuralgia (a chronic painful disease that affects the nerve that carries sensation from the face to the brain). This placed the resident at risk of uncontrolled pain.Findings included:- R6's Electronic Medical Record (EMR) revealed a diagnosis of trigeminal neuralgia.R6's Significant Change Minimum Data Set (MDS), dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received scheduled and as-needed (PRN) pain medications and reported she had occasional pain, which rarely affected her day-to-day activities and sleep. The MDS noted R6's worst pain in the past five days was rated at a five on a one to 10 pain scale (one being minimal pain and 10 the worst pain…

    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 · Fcited before2024-01-25 · 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 34 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour on 01/24/24 at 07:53 AM, the following areas of concern were noted: 1. Six plastic cutting boards had deep grooves, making the boards unsanitizable. 2. One large cutting board was put away as clean but contained a large coffee stain. 3. A cabinet to store clean dishes had shelving paper which was stained brown in areas and had a build-up of dust along the edges of the cabinet. The cabinet also had multiple areas of a dried on food substance. 4. Six wire racks in one two-door reach-in refrigerator had the protective coating missing from the tips of the wire racks, making them unsanitizable. 5. The stationary can open had a build-up of a black, sticky substance around the point of the opener which goes into the can while opening. 6. An unopened cardboard box containing 1000 10…

    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 · Fcited before2024-01-25 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34 residents with 14 selected for review, which included one resident reviewed for antibiotic use. Based on observation, interview and record review, the facility failed to ensure Resident (R)27 received an appropriate antibiotic, based on culture report. The facility failed to track and trend causative microorganisms for infections and use of appropriate antibiotics. Findings included: - Review of Resident (R)27's Physician Order Sheet, dated 01/02/24, revealed diagnoses that included rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), major depressive disorder (major mood disorder which causes persistent feelings pf sadness) and peripheral vascular disease (slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-25 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — the official record, unedited, may be distressing

    The resident reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff in the facility kitchen. Findings included: - During the initial tour of the kitchen on 01/24/24 at 07:53 AM, the following area of concern was noted: The parameter of the floor and the floor where the table legs rested had a heavy build-up of dirt, trash, and discolored grime. On 01/25/24 at 10:50 AM, Administrative Staff A confirmed the areas of concern. The facility policy for Sanitation of Dining and Food Service Areas, undated, documented the dining services staff will uphold sanitation of the dining areas according to a thorough, written schedule. Staff will be held responsible for all cleaning tasks. The facility failed to provide a safe, functional, sanitary, and comfortable environment for staff and residents in the facility kitchen.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-25 · 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

    - Observation on 01/23/24 and 01/24/23 of Resident (R)1's room revealed the floor with multiple areas of a sticky substance. The over bed table contained rust and a build-up of grime on the base of the table. The room contained a recliner with multiple pillows without pillowcases, and the resident's dresser tops contained unorganized supplies and personal items. Interview, on 01/24/24 at 08:06 AM, Licensed Nurse (LN) H, revealed the resident remained in bed most of the time. LN H stated the floor was dirty and the room needed to be cleaned. Interview, on 01/24/24 at 10:37 AM, with Housekeeping Staff U, revealed housekeeping cleaned R1's room every other day as the resident was in isolation. Housekeeping Staff U stated nursing staff would be responsible for organization of items in the resident rooms. The facility policy Resident Room Cleaning undated, instructed staff to daily clean resident rooms, pick up all trash, mop the floor, move furniture and beds to thoroughly clean. The facility failed to ensure staff maintained this dependent resident's room in a sanitary and homelike…

    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 before2024-01-25 · 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 reported a census of 34 residents with 16 selected for review. Based on observation, interview and record review, the facility failed to revise one Resident (R)1's care plan to include care and treatment of her urinary catheter and failed to revise R4's care plan to include use of a pressure reducing device when sitting in her recliner. Findings included: - Review of Resident (R)1's Physician Order Sheet, dated 01/02/24, revealed diagnoses that included neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), muscle weakness, arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement) and neuralgia (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34 residents with 14 residents sampled, including two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review, the facility failed to provide facial grooming for one of the two sampled Residents (R)28 regarding the trimming of his beard and mustache. Findings included: - Review of Resident (R)28's electronic medical record (EMR) revealed the following diagnoses: Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and hemiplegia (paralysis on one side of the body). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. He required extensive assistance of two staff for personal hygiene and had an impairment in functional range of motion (ROM) on one side of his upper…

    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 before2024-01-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34 residents with 14 selected for review which included two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation interview and record review, the facility failed to provide sanitary dressing change for one Resident (R)1 pressure ulcer and failed to implement pressure relieving device in R4's recliner. Findings included: - Review of Resident (R)1's Physician Order Sheet, dated 01/02/24, revealed diagnoses that included neuromuscular dysfunction of bladder (neurogenic bladder: the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), muscle weakness, arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement) and neuralgia (weakness, numbness, and pain from nerve damage, usually in the hands and feet). 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 · Dcited before2024-01-25 · 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 34 residents with 14 residents sampled, including two residents reviewed for accidents. Based on interview, record review and observation, the facility failed to ensure one Resident (R)31 was kept free of accident hazards by failing to ensure her urinary catheter tubing (insertion of a catheter into the bladder to drain the urine into a collection bag) was contained to prevent a tripping hazard. Findings included: - Review of Resident (R)31's electronic medical record (EMR) revealed the following diagnoses: retention of urine (lack of ability to urinate and empty the bladder) and weakness. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She required substantial to maximal staff assistance to transfer from her bed to her wheelchair and partial to moderate staff assistance to go from lying to sitting on the side of her bed. She had an indwelling urinary…

    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 before2024-01-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34 residents with 14 selected for review which included three residents reviewed for urinary catheter. Based on observation, interview and record review, the facility failed to ensure proper catheter care with securing of the catheter for one Resident (R)1 of the three residents reviewed, to prevent urethral trauma. Findings included: - Review of Resident (R)1's Physician Order Sheet, dated 01/02/24, revealed diagnoses that included neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), muscle weakness, arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement) and neuralgia (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. 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 · Dcited before2024-01-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34 residents with 14 selected for review. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure to provide a sanitary room environment for Resident (R)1 and failed to provide sanitary drainage of urinary catheter for R31 to prevent cross contamination and infections. Findings included: - Review of Resident (R)1's Physician Order Sheet, dated 01/02/24, revealed diagnoses that included neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), muscle weakness, arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement) and neuralgia (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine which indicated…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-06-09 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 41 residents. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental, and psychosocial wellbeing of the residents residing in this facility. Findings included: - Review of the staffing records revealed the facility lacked staff postings with hours worked. Review of the [Facility] Assignment Sheets, revealed the following areas of concern: On 03/05/22, night shift (10:00PM- 6:00AM,) the North hall, had one Licensed Nurse (LN) and no Certified Nurse Aide (CNA.) On 03/11/22 evening shift (2:00 PM - 10:00PM,) the North hall, had one LN and one CNA. On 03/16/22, night shift, the South hall, had one LN and no CNA, and the North hall, had one LN and one CNA. On 03/29/22, evening shift, one LN and one CNA. On 04/06/22, night shift, the North hall, had one LN with no CNA, and the South hall, had one LN with one CAN. On 05/16/22, day shift (6:00 AM- 2:00 PM,) the North hall, had one LN and one CNA with a floating 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-06-09 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 41 residents. Based on record review and interview, the facility failed to ensure nursing staff followed the principles of antibiotic stewardship in a proactive manner to ensure residents received antibiotics in a safe and effective manner and to prevent unnecessary side effects of antibiotics and antibiotic resistance. The facility failed to track and trend infections and causative microorganisms throughout the facility and failed to compile antibiotic use data for prescribing practitioners. Findings included: - Review of the Infection Tracking notebook, revealed a map of the facility units with color coded key for various infections, such as urinary tract, respiratory and skin. The notebook contained a section for urinary tract infections and antibiotic prescribed and contained a section for non-urinary tract infection with antibiotic prescribed but the notations lacked causative organisms. Review of the log for February 2021, revealed an unsampled resident (R)21 with a urinary tract infection. The culture result showed MRSA (Methicillin Resistant…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-06-09 · tag F0887 — widespread
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 41 residents with 2 identified as unvaccinated residents. Based on interview and record review the facility failed to ensure staff provided COVID-19 vaccination information/education which included benefit verses risk to ensure informed declination. The facility failed to ensure prompt preparation for administration of the COVID-19 booster to the residents which was available on 05/19/22. The facility currently had five residents with COVID-19 and was in outbreak testing. Findings included: - Review of resident (R) 28's medical record revealed the resident admitted to the facility on [DATE] and lacked a signed declination form. Review of R 27's medical record revealed the resident admitted to the facility 08/05/21 and lacked a signed declination form. Interview, on 06/08/22 at 01:20 PM, with Administrative Nurse D, confirmed staff did not obtain the declination forms to verify the facility provided information/education to include benefit verses risk for COVID-19 vaccine upon…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-09 · 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 reported a census of 41 residents. Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment in a storage room and in the biohazard room, for the residents of the facility. Findings included: - During an environmental tour on 06/08/22 at 10:27 AM with Housekeeping/Maintenance staff U, revealed the following concerns: The north hall storage room had multiple cardboard boxes resting directly on the floor. These boxes contained resident care use items including; One box contained 24 cold compresses, one box contained 2,500 count 3.5 ounce (oz) clear plastic cups, one box contained 50 count nebulizer tubing and one box contained eight bottles of sani cloth bleach wipes. On 06/08/22 at 10:27 AM, Housekeeping/Maintenance staff U stated there was nowhere else to store the boxes except directly on the floor. On 06/08/22 at 10:50 AM, the biohazard closet had two full biohazard bags resting directly on the floor. On 06/08/22 at 10:50 AM, Housekeeping/Maintenance staff U stated there was nowhere else to store the full…

    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 before2022-06-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents. The 15 residents sampled included four reviewed for urinary incontinence. Based on observation, interview and record review, the facility failed to provide toileting opportunity/check and change opportunity in a timely manner for three of the four sampled residents (R)15, R40, R27 and failed to provide perineal hygiene in a sanitary manner for four of the four sampled residents R15, R23, R40 and R 27. Findings Included: - Review of resident (R) 15's Physician Order Sheet, dated 03/16/22 revealed diagnoses included psychosis (any major mental disorder characterized by a gross impairment in reality), peripheral vascular disease (abnormal condition affecting the blood vessels), and urinary tract infection. The Annual Minimum Data Set (MDS), dated [DATE] assessed the resident with normal cognitive function the resident required extensive assistance of two staff for bed mobility, toileting, and personal hygiene. The resident was always incontinent of bowel and bladder,…

    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 · D2022-06-09 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 41 residents. The 15 residents selected for review included one resident reviewed for choices. Based on observation, interview and record review, the facility failed to provide a bathing choice opportunity for the one resident (R)9 who requested a shower. Findings included: - Review of resident (R)9's Physician Order Sheet, dated 05/02/22, revealed diagnoses included hypoosmolality (a condition where levels of electrolytes, nutrients and proteins are lower than normal), hyponatremia (low sodium concentration in the blood), major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognition. The resident required limited assistance with transfer, dressing and personal hygiene. The resident had no impairment in the upper or lower extremities. The ADL (Activities of Daily Living) Care Area Assessment…

    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 before2022-06-09 · 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 reported a census of 41 residents with 15 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plan for one sampled Resident (R)20, regarding oxygen use. Findings included: - Review of Resident (R)20's electronic medical record (EMR), under the Medical Diagnosis tab, included a diagnosis of chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She had shortness of breath (SOB) with exertion. She did not receive oxygen. The Cognitive Loss/Dementia Care Area Assessment' (CAA), dated 03/23/22, documented the resident was able to make her needs known at times, but also required cueing. The quarterly MDS, dated 12/29/21,…

    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 · D2022-06-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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 41 residents. The 15 residents sampled included two reviewed for other skin issues. Based on observation, interview and record review the facility failed to provide thorough incontinence hygiene care and treatment, in a timely manner, to prevent moisture associated skin damage to one of the two sampled residents (R)15. Findings Included: - Review of resident (R) 15's Physician Order Sheet, dated 03/16/22 revealed diagnoses included psychosis (any major mental disorder characterized by a gross impairment in reality), peripheral vascular disease (abnormal condition affecting the blood vessels), and urinary tract infection. The Annual Minimum Data Set (MDS), dated [DATE] assessed the resident with normal cognitive function the resident required extensive assistance of two staff for bed mobility, toileting, and personal hygiene. The resident was always incontinent of bowel and bladder, and at risk for pressure ulcers. The resident had moisture associated skin damage (MASD…

    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 before2022-06-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with 15 residents sampled, including two residents reviewed for pressure ulcers (PU). Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services for one of the Residents (R)40, for failure to prevent the development of one stage II PU (partial thickness skin loss). Findings included: - Review of Resident (R)40's electronic medical record (EMR), under the Med Diag tab, included a diagnosis of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. He required extensive assistance of two staff for bed mobility and transfers and had functional impairment in range of motion (ROM) on one side of his lower…

    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 · D2022-06-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents. The 15 residents sampled included four residents reviewed for hydration. Based on observation, interview and record review, the facility failed to ensure one of the four sampled residents (R)9 received a planned fluid restriction, and failed to monitor accurately the resident's fluid intakes, per physician's order. Findings included: - Review of resident (R)9's Physician Order Sheet, dated 05/02/22, revealed diagnoses included hypoosmolality (a condition where levels of electrolytes, nutrients and proteins are lower than normal), hyponatremia (low sodium concentration in the blood), major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognition. The resident required supervision with eating and had no impairment in the upper and lower extremities. The resident had no chewing or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-09 · 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 41 residents with 15 residents sampled, including one resident reviewed for respiratory needs. Based on interview, record review, and observation, the facility failed to obtain a physician order to appropriately administer oxygen to the one sampled Resident (R)20, who used oxygen. Findings included: - Review of Resident (R)20's electronic medical record (EMR), under the Medical Diagnosis tab, included a diagnosis of chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She had shortness of breath (SOB) with exertion. She did not receive oxygen. The Cognitive Loss/Dementia Care Area Assessment' (CAA), dated 03/23/22, documented the resident was able to make her needs known 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-09 · 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

    - Review of resident (R)5's Physician Order Sheet, dated 03/03/22, revealed diagnosis included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (MDD, major mood disorder), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The resident's, Psychotropic Drug Use Care Area Assessment (CAA), dated 09/08/21 assessed the resident was prescribed antidepressants, anti-anxiety and hypnotic medications. The Care Plan, reviewed 04/18/22, instructed staff the resident deterioration was expected due to physical and mental status due to multiple end stage disease responses. The resident received Clonazepam for anxiety, Sertraline for depression, Wellbutrin for depression and Amitriptyline for insomnia. Staff instructed to document 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-01-25 · tag F0730 — widespread
    Observe 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 reported a census of 34 residents. Based on interview and record review the facility failed to complete an annual performance review at least once every 12 months for four of four Certified Nurse Aides (CNA) reviewed, CNA N, CNA P, CNA Q and CNA MM and one of one Certified Medication Aide (CMA) reviewed, CMA S. Findings included: - Review of these four Certified Nurse Aide (CNA) and one Certified Medication Aide (CMA) personnel files, revealed the following concerns: 1. CMA S, hired 05/01/22, lacked an annual performance review in her personnel file. 2. CNA P, hired 05/01/22, lacked an annual performance review in her personnel file. 3. CNA Q, hired 09/26/22, lacked an annual performance review in his personnel file. 4. CNA MM, hired 05/01/22, lacked an annual performance review in her personnel file. 5. CNA N, hired 05/01/22, lacked an annual performance review in her personnel file. The facility handbook, undated, included: Full-time and part-time employees shall receive formal, written evaluations on an annual basis within two weeks of the employee's anniversary…

    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
  • No harm found · C2022-06-09 · 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 41 residents. Based on interview and record review, the facility failed to post the daily nurse staffing with the resident census and hours worked as required for the residents, staff and visitors of the facility. Findings included: - Observation on 06/06-06/09/22 revealed a lack of posted daily nurse staffing with the resident census and hours worked. Review of the [Facility] Assignment Sheets, revealed the following areas of concern: On 03/05/22, night shift (10:00PM- 6:00AM,) the North hall, had one Licensed Nurse (LN) and no Certified Nurse Aide (CNA). On 03/11/22, evening shift (2:00 PM - 10:00PM,) the North hall, had one LN and one CNA. On 03/16/22, night shift, the South hall, had one LN and no CNA, the North hall, had one LN and one CNA. On 03/29/22, evening shift, the North hall, had one LN and one CNA. On 04/06/22, night shift, the North hall, had one LN with no CNA, and the South hall, had one LN with one CAN. On 05/16/22, day shift (6:00 AM- 2:00 PM,) then North hall, had one LN and one CNA with a floating staff CNA. On 05/23/22, night…

    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

$42,224 in federal fines across 2 penalties.

  • $16,377 — penalty dated 2024-05-06
  • $25,847 — penalty dated 2023-12-20

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 MEDICALODGES, INC. — 18 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 2 of 52.7-0.7 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 4 of 53.6+0.4 vs chain
Quality measures 2 of 52.8-0.8 vs chain
The other 17 homes this chain runs (chain average 2.7★, per CMS)

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
MEDICALODGES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2022
BARTLEY, TRACYIndividualW-2 MANAGING EMPLOYEEsince 05/01/2022
BUTLER, RICHARDIndividualCORPORATE DIRECTORsince 07/01/2003
COX, GARENIndividualCORPORATE DIRECTORsince 02/26/1988
DOLL, GAYLEIndividualCORPORATE DIRECTORsince 03/06/2005
HINES, SCOTTIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/20/2009
LAGER, SHANNONIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/23/2018
MARSHALL, CAROLIndividualCORPORATE DIRECTORsince 07/27/2006
OTT, RONIndividualCORPORATE DIRECTORsince 09/15/2006
CARDENAS, STACIIndividualCORPORATE OFFICERsince 07/01/2014
COOVER, TERESAIndividualCORPORATE OFFICERsince 09/21/2017
LANTZ, KATHLEENIndividualCORPORATE OFFICERsince 11/01/2013
MCBRIDE, TRAVISIndividualCORPORATE OFFICERsince 11/01/2013
ROHLING MCCORD, CATHERINEIndividualCORPORATE OFFICERsince 06/09/2000
SMITH, PAMELAIndividualCORPORATE OFFICERsince 07/01/2014
WAECHTER HARMON, LORIIndividualCORPORATE OFFICERsince 03/31/2018

CMS files one row per role, so the 18 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$4.1M
Net patient revenuemost recent cost report
-2.4%
Operating marginrevenue minus expenses
$217K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 11%Other / private 89%

This home reported $217K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$285per resident / day
operating cost
$8,675per month
≈ monthly operating cost
$279per 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 175226. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, 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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