Wichita County Health Center Ltcu
211 East Earl Street, Leoti, KS 67861 · Government - County · 10 certified beds · (620) 375-2233 Medicaid only — no Medicare
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | Not rated |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.0% | 17.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 12.5% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 4.2% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 4.3% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 3.7% | 16.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.7% | 23.2% | 18.9% | better |
| Long-stay residents with pressure ulcers | 0.0% | 4.4% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 0.0% | 22.6% | 21.2% | check this* — see note marked star below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.8% | 18.1% | 17.1% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. Inspectors cited this home for failing to submit its staffing data to CMS (F0851) — see the citation below. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Fcited before2025-06-03 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 10 residents. Based on observation, interview, and record review, the facility failed to employ a full-time Certified Dietary Manager for the 10 residents who received their meals from the facility kitchen. This deficient practice placed the residents at risk of not receiving adequate nutrition. Findings included: - On 06/01/25 at 08:55 AM, observation in the facility's kitchen revealed three dietary staff working. On 06/02/25 at 09:10 AM, Dietary Staff BB verified she did not have certification as a Dietary Manager. She stated she had taken the coursework but not a test to become certified. On 06/03/25 at 08:00 AM, Administrative Nurse D verified the dietary manager was not certified. Administrative Nurse D was aware that the facility should have a Certified Dietary Manager. The facility's Dietary Manager policy, dated 10/26/22, stated the Dietary Manager would supervise food preparation and service, dietary supplies, conduct training for the dietary department, and maintain certified dietary manager credentials. The Dietary Manager would communicate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-06-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of 10 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary condition for 10 residents who reside in the facility and received meals from the facility's kitchen, placing them at risk for foodborne illness. Findings included: - On 06/01/25 at 08:55 AM, the facility kitchen had three dietary staff cleaning and preparing food. The walk-in refrigerator had opened but undated containers of macaroni salad, black olives, cottage cheese, and one eight-pound box of Deli salad. On 06/01/25 at 09:00, Dietary Staff (DS) CC verified the opened, undated foods. On 06/02/25 at 09:10 AM, DS BB verified staff were to date packages of food when they opened them. The facility's Food Storage policy, dated 10/05/23, stated leftover food would be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated.
- Potential for harm · D2025-06-03 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 10 residents. Based on observation, interview, and record review, the facility failed to provide a Bed Hold Notice to Resident (R) 2 or her representative, upon transfer and admission to a hospital. This deficient practice placed R2 at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R2's Electronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (elevated blood pressure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and heart disease. R2's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R2 had re-entered the facility from a skilled nursing facility and required staff assistance with most activities of daily living. R2's Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 10 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to date insulin (a hormone that lowers the level of glucose in the blood) subcutaneous (beneath the skin) injectable pens with an open date and expiration date for Resident (R) 2 and R6. This deficient practice placed the residents at risk of receiving outdated medication that may cause adverse consequences. Findings included: - On [DATE] at 09:04 AM, during an initial tour of the medication room R2's Basaglar (long-acting insulin) and R10's Lantus (long-acting insulin) pens stored in the medication room refrigerator lacked open and expired dates. Licensed Nurse (LN) H verified the in-use pens stored in the medication room refrigerator lacked open and expired dates. On [DATE] at 09:01 AM, Administrative Nurse D verified the insulin pens in use should be labeled with open and expiration dates. The facility's Medication Administration Subcutaneous Injection policy,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-20 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of eight residents. The sample included eight residents. Based on record review and interview, the facility failed to ensure licensed nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed all residents at risk for decreased quality of care. Findings included: - The facility Facility Assessment, dated 04/25/2019, documented nursing of personal care, enteral feedings (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food), wound and skin integrity, pain management, fall reduction program, diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) management, orthopedic (pertaining to bones) management, palliative (treatment designed to relieve or reduce intensity of uncomfortable symptoms)/hospice care (end of life care), cardiovascular (pertaining to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-20 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to employ a full time certified dietary manager for the eight residents who resided in the facility and received meals from the facility kitchen. This deficient practice placed the eight residents at risk for receiving inadequate nutrition. Findings included: - On 09/18/23 at 08:20 AM, observation revealed six dietary staff preparing and serving meals in the facility's temporary kitchen. The facility kitchen was under construction and currently empty. Staff were using two dorm size refrigerators and the walk-in refrigerator and freezer. Staff served meals on disposable plates with regular cups and silverware. On 09/18/23 at 08:20 AM, Dietary Staff BB stated she was not certified in dietary management and had been taking those classes since January 2023. On 09/20/23 at 12:00 PM, Administrative Staff A stated the facility was aware the dietary manager needed to be certified. She stated the current dietary manager had been enrolled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to monitor refrigerator temperatures, sanitation during dishwashing, and failed to ensure thorough coverage of hair when serving meals. This deficient practice placed the eight residents of the facility at risk for food borne illness. Findings included: - On 09/18/23 at 08:20 AM, observation revealed six dietary staff preparing meals in the facility's temporary kitchen. The facility kitchen was under construction and currently empty. Staff were using two dorm size refrigerators and the walk-in refrigerator and freezer. Staff served meals on disposable plates with regular cups and silverware. On 09/18/23 at 11:45 AM, observation revealed one of six dietary staff with a moderate amount of hair outside of the back of the hairnet. On 09/19/23 at 07:45 AM, observation revealed Dietary Staff (DS) BB plated breakfast items from the steam table for residents with many long hairs dangling out of her hairnet. The Temperature Log 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.
- Potential for harm · Fcited before2023-09-20 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of eight residents. Based on interview, and record review the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all direct care personnel as required. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2022 Quarter 4 and FY 2023 Quarters 1 through 3 indicated data was suppressed though the facility did not meet the reasons for suppressed data other than inaccurate data or failure to report. On 09/20/23 at 10:36 AM, Administrative Nurse D reported he was now submitting the staffing information to CMS, and the staff who did it prior must have submitted the incomplete nursing coverage. Upon request the facility did not provide PBJ submission policy. The facility failed to submit accurate information to CMS PBJ as required.
- Potential for harm · Dcited before2023-09-20 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 8 had a physician's order and was assessed for the ability to safely self- administer topical (on the surface of the body) medication, which placed R8 at risk of improper use of medication and related side effects. Findings included: - R8's Electronic Medical Record (EMR) recorded diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), frequent falls, hypertension (elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment, exhibited no behaviors, required limited assistance of one staff with transfers, walking, toilet use and personal hygiene. R8 was not steady and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to notify the state Long Term Care Ombudsan (LTCO) of Resident (R)3's discharge to a hospital in July 2023. This deficient practice placed R3 at risk for impaired rights due to decreased oversight of transfers. Findings included: - R3's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R3 was independent with all activities of daily living (ADL). R3's Care Plan dated 07/07/23 directed R3 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2023-09-20 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to provide a copy of the Bed Hold notice to Resident (R)3, or her representative, upon discharge to a hospital in July 2023. This deficient practice place R3 at risk to not be allowed to return to their same room upon discharge from the hospital. Findings included: - R3's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R3 was independent with all activities of daily living (ADL). R3's Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight resident. The sample included eight residents. Based on observation, record review, and interview, the facility failed to revise the care plan with effective interventions for Resident (R) 8 who had over 60 falls in four months. This placed R8 at risk for ongoing falls and injury due to uncommunicated care needs. Findings included: - R8's Electronic Medical Record (EMR) diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), frequent falls, hypertension (elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment, exhibited no behaviors, required limited assistance of one staff with transfers, transfers, walking, toilet use and personal hygiene. R8 was not steady and only able to stabilize with staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to document and assess a skin injury of unknown origin to Resident (R) 1 which required treatment. This deficient practice placed R1 at risk for impaired skin care and treatment for her injury and risk for further injuries. Findings included: - R1's Electronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), and macular degeneration (progressive deterioration of the retina). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one, indicating severely impaired cognition. The MDS documented R1 required total staff assistance with all activities of daily living, had impaired range of motion (ROM) in both lower extremities and used a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents. Based on observation, interview and record review, the facility failed to investigate causative factors and implement relevant interventions, including changing interventions which were ineffective, to prevent falls for Resident (R) 8 who had over 60 falls in four months and for R5. The facility further failed to assess R5 for the safe use of an electric recliner. This placed the residents at further risk of injuries from falls and preventable accidents. Findings included: - R8's Electronic Medical Record (EMR) diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), frequent falls, hypertension (elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents, with five reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 2's use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions). This placed the resident at risk for inappropriate use of an antipsychotic medication with side effects. Findings include: - R2's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) with behavioral disturbance, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest.) R2's admission Minimum Data Set (MDS), dated [DATE], recorded R2 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents, with five reviewed for unnecessary medications. Based on observations, interview and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use for Resident (R)2's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing). This placed R2 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R2's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) with behavioral disturbance, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest.) R2's admission Minimum Data Set (MDS), dated [DATE], recorded R2 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to label Resident(R)3's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen, stored in the medication room, with the date opened. This deficient practice placed the affected resident at risk for ineffective medications. Findings included: - On [DATE] at 08:20 AM, observation of the facility's medication room revealed the following: R3's Levemir (long-acting insulin) flex pen lacked an open date and expiration date. On [DATE] at 08:25 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the expired insulin. On [DATE] at 10:00 AM, Administrative Nurse E verified the nurses should label and date the flex pens with the resident's name and discard expired pens. Upon request the facility's lacked a Storage of Medication policy. The facility failed to label, and date the resident's insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-14 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of eight residents and the sample included all eight. Based on observation, record review and interview the facility failed to resolve grievances recorded during Resident Council meetings and failed to inform the resident's how to file a grievance. This placed the residents at the facility at risk for unresolved grievances and decreased quality of life. Findings included: - Review of the Resident Council Minutes from May 2021 to May 2022 recorded four documented grievances from the Resident Council which staff had not addressed the residents' concerns regarding staff not announcing themselves upon entrance to resident rooms and the staff's facility name badges being unreadable. Review of the facility Grievance/Variance Log from June 2021 to June 2022 recorded only one grievance in August 2021. On 07/12/22 at 03:30 PM, three facility residents met with the surveyor to discuss the resident council. The residents verbalized the residents had concerns and grievances with staff not announcing themselves upon entrance to their rooms and the staff's name badges…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-14 · tag F0700 — widespreadTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents, with eight reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess Resident (R)9's, R2, R4, R3, R 1, R5, R7, and R8 side rails for safe use and failed to ensure the openings (gaps) in the siderails met stardards of practice to prevent entrapment. This placed the residents at risk for injury. Findings included: - R9's diagnosis included hypertension (elevated blood pressure), emphysema (long-term, progressive disease of the lungs characterized by shortness of breath), iron deficiency anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R9 had a Brief Interview for Mental Status (BIMS) score of 15, indicating. intact cognition. The assessment revealed R9 required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-14 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of eight residents. The sample included eight residents. Based on observation, record review and interview the facility failed to ensure their Medical Director attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings, and the facility failed to have quarterly meetings. This placed the eight residents who resided in the facility at risk for lack of quality care. Findings included: - The facility provided QAA committee attendance rosters for 06/21/22, 06/06/22 and 04/13/22 in which the medical director had not been present. The facility only provided documentation for two quarters of the four required for the year 2021-2022. On 07/14/22 at 12:30 PM, Administrative Nurse E verified the QAA meetings should be held quarterly and were to include the medical director. On 07/14/22 at 12:30 PM Administrative Staff A verified the lack of quarterly meetings, and stated the medical director came to the facility every Monday for meetings with other providers. Administrative Staff A stated going forward, the facility would probably just ask her to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-07-14 · tag F0657 — failed to keep the care plan current — patternDevelop 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 had a census of eight residents. The sample included eight residents, with eight reviewed for accidents/side rails. Based on observation, record review, and interview, the facility failed to update Resident (R)9, R2, R4, R3, R1, R5, and R8s' care plan for the use of side rails. This placed the affected residents at risk for risk of side rail related injuries and uncommunicated care needs. Findings included: - R9's diagnosis included hypertension (elevated blood pressure), emphysema (long-term, progressive disease of the lungs characterized by shortness of breath), iron deficiency anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R9 had a Brief Interview for Mental Status (BIMS) score of 15, indicating. intact cognition. The assessment revealed R9 required limited staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-07-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of eight residents. The sample included eight residents and one medication room Based on observation, interview, and record review, the facility failed to discard expired stock medication in one medication room. This placed these residents at risk for ineffective medications. Findings included: - On 07/11/22 at 12:00 PM, observation of the medication room revealed one bottle of Citrucel (bulk-forming laxative) 16.9 ounces (oz), expired 02/22. On 07/11/22 at 12:05 PM, Licensed Nurse (LN) G, verified the stock medications in the medication room had expired. LN G stated the nurses were to look at the bottles and verify expiration dates before administering the medications to the discard expired medications. LN G stated the pharmacy had just recently delivered the stock medication to the facility. On 07/13/22 at 4:00 PM, Administrative Nurse D verified expired stock medications should be discarded; the nurses would check the stock medication delivered by the pharmacy for expiration dates before use. The facility's Medication Labeling and Storage policy,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents. Based on observation, interview and record review the facility failed to assess Resident (R) 8, R9 and R7 for the ability to self-administer his own medications safely. This deficient practice placed R8 at risk for medication errors and adverse effects. Findings included: - Resident (R) 8's Physician Order Sheet (POS), dated 6/30/22, documented diagnoses of macular degeneration (causes loss in the center of the field of vision), and spinal stenosis (narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R8 independent for all activities of daily living, balance steady at all times, used a cane, and had no falls since the previous MDS. The MDS documented R8 received scheduled and as needed pain medication,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents. Based on observation, interview and record review the facility's pharmacy failed to provide the correct dosage packaging of Lyrica (used to treat pain from nerve damage, anxiety, or seizures) for Resident (R) 7, when the pharmacy packaged the total Lyrica dose for a three times a day dosing into one blister pack. This deficient practice contributed to a medication error which caused lethargy (drowsiness or aversion to activity as is induced by disease, injury, or drugs) and R7 was hospitalized overnight for observation. Findings included: - Resident (R) 7's Physician Order Sheet (POS), dated 06/14/22, documented diagnoses of anxiety (nervous disorder characterized by a state of excessive uneasiness and apprehension), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and a history of drug overdose 04/27/22. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-14 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents. Based on observation, interview and record review the facility failed to ensure Resident (R) 7 received the correct dosage of Lyrica (used to treat pain from nerve damage, anxiety, or seizures) per physician orders. This deficient practice caused lethargy (drowsiness or aversion to activity as iinduced by disease, injury, or drugs) and R7 was hospitalized overnight for observation. Findings included: - R7's Physician Order Sheet (POS), dated 06/14/22, documented diagnoses of anxiety (nervous disorder characterized by a state of excessive uneasiness and apprehension), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and a history of drug overdose 04/27/22. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R7 independent with all activities of daily living, balance steady at all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-14 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of eight residents. The sample included eight residents with one reviewed for dental care. Based on observation, record review and interview, the facility failed to offer and/or provide timely dental assessment and care for Resident R(9). This placed R9 at risk for weight loss, and dental issues. Findings included: - R9's diagnosis included hypertension (elevated blood pressure), emphysema (long-term, progressive disease of the lungs characterized by shortness of breath), iron deficiency anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R9 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment revealed the resident required limited staff assistance for personal hygiene, dressing and had no oral or dental issues. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-06-03 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 10 residents. Based on observation, record review, and interview, the facility failed to display accurate nursing personnel hours for staff responsible for providing direct care accessible to residents and visitors. Findings included: - During the survey period of 06/01/25 to 06/03/25 the facility posted nursing staff by name and shift but lacked the facility's census and direct care nursing staff hours of nursing. On 06/03/25 at 08:00 AM, Administrative Nurse D reported using a different scheduling system and believed the posting was accurate, related to who and when direct care staff worked but lacked totaled hours. The facility's Posting Daily Nurse Staffing Form policy, dated 06/03/25, documented the Director of Nursing or designee would ensure that the number of registered nurses, licensed practical nurses and certified nurse aides (Direct Care Partners) scheduled for each day, the name of the facility, census of the facility, and total number of hours of each position listed in posted at the entrance to the health center and would be kept current…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2025-06-03 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 10 residents. Based on record review and interviews, the facility failed to submit complete and accurate staff information through the Payroll-Based Journal (PBJ) as required. Findings included: - The PBJ report provided by the Centers for Medicare &Medicaid Services (CMS) for Fiscal Year (YR) 2024 Quarter (Q) 2 and Q3, indicated excessively low weekend staffing. The PBJ further indicated that Q4 lacked licensed nurse coverage for 24 hours, seven days in August, and one day in September 2024. A review of the facility's weekend and licensed nurse hours on the dates listed on the PBJ revealed appropriate weekend and licensed nurse coverage. On 06/02/25 at 08:00 AM, Administrative Nurse D reported that the discrepancy may be related to the vendor the facility used to submit PBJ information to CMS had not been accurate. The facility's undated Mandatory Submission of Uniform Format Staffing Information (PBJ) documented the facility will electronically submit to CMS complete and accurate direct care staffing information, including information for agency and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-09-20 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to review resident rights routinely with the eight residents of the facility. Findings included: - Review of the Resident Council minutes for the past 12 months revealed no documentation residents' rights were discussed or reviewed during the meetings. On 09/19/23 at 01:40 PM, during an interview regarding the Resident Council, Resident (R) 5 and R6 stated the staff did not review residents' rights with them. On 09/19/23 at 02:32 PM, Administrative Nurse D verified staff had not documented the resident rights were reviewed routinely during resident council meetings or any other time. The facilities Resident Rights policy stated the facility must establish and maintain policies regarding transfer, discharge, and the provision of services under the state plan for all residents. The facility failed to review resident rights routinely with the eight residents of the facility.
- No harm found · C2023-09-20 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to post, as required, the past three years of survey and complaint review results (a 2567 form) in a public place accessible to residents and the public. Findings included: - On 09/18/23 at 04:55 PM, observation revealed the last survey or complaint report posted was dated 04/16/19. The most recent health resurvey report, dated 07/14/22, and a complaint visit result form, dated 12/14/22, was not posted. On 09/18/23 at 05:00 PM, Administrative Nurse D verified the survey results were not posted in a public place. The facility did not provide a policy for posting survey results. The facility failed to post, the required previous survey and complaint review results in a public place accessible to residents and the public.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in KS
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 17E011. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-03, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.