Southwest Medical Center SNF
315 W 15th Street, Liberal, KS 67905 · Government - County · 18 certified beds · (620) 629-6291 Medicare only — no Medicaid
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
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 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 fell from 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 73.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.1% | 22.4% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.6% | 11.5% | 12.0% | typical |
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.
65.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 141 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 11.1% 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 90 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.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 65.8%CMS range 59.9–73.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 8.9–16.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 11.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 7.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 80.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.6%CMS range 2.5–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.59 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · F2026-04-22 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide eight consecutive hours of Registered Nurse (RN) staff daily for the residents of the facility.Findings included:- The 08/05/25 Facility Assessment, documentation included: Staff/Personnel required, which stated Skilled Nursing Unit bases staffing on the resident population and their needs for care and support. A good faith effort and approach is made to ensure sufficient, qualified staff is available to meet the needs of the residents at any given time. The staffing plan in place can be adjusted based on changes in the resident census. The nurse to resident ratio is six residents to one RN and one Certified Nurse Aide. An additional Licensed Practical Nurse (LPN) may be utilized if the resident number increases. Staff are scheduled 12 hours shifts per day. Review of the Nursing schedule for 10/01/25 - 12/31/25, revealed a lack of scheduled RN coverage for the following dates:Thursday, 11/13/25.Sunday, 11/20/25.Saturday, 12/20/25. On 04/22/26 at 01:33 PM, Administrative Nurse E confirmed the lack of…
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 before2026-04-22 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observation and record review, the facility failed to utilize 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) when providing direct care to a Resident (R) 11 with a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer. The facility further failed to ensure adequate hand hygiene before medication administration for R11 and R2. Findings included:1. On 04/21/26 at 08:53 AM, Licensed Nurse (LN) G sanitized her hands and applied gloves, LN G did not apply any other personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) and entered R11's room with his medications in their blister packs. LN G placed the medications on the counter under the computer in his room. LN G then assisted R11 to sit up in his bed, as he had laid flat in the bed diagonally. LN G applied the gait belt on R11 and assisted him to the side of 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 · E2026-04-22 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a written baseline care plan to Resident (R) 1, R2, 11, and R4. Findings include:- On 04/20/26 at 09:51 AM, R1 reported she had not received a copy of a baseline care plan. She reported that she has not attended a care plan meeting or any discharge planning since she admitted . R1's Electronic Medical Record (EMR) lacked documentation that a written baseline care plan was given or reviewed by R1 or a family member since she admitted on [DATE]. On interview on 04/20/26 at 10:24 AM, R2 reported she was never provided a written copy of the care plan while she had been a resident in this facility.R2's EMR lacked documentation that a written baseline care plan was given or reviewed to R2 or a family member since she admitted on [DATE]. On 04/20/26 at 10:28 AM, R11 reported he was uncertain about a baseline care plan and reported he did not receive any paperwork about a care plan.R11's EMR lacked documentation that a written baseline…
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 · E2026-04-22 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to store and label biologicals adequately when staff failed to date an insulin (medications used to treat high blood glucose levels) pen when opened. Findings included:- On 04/21/26 at 09:50 AM, observation of the Resident (R) 1's Lantus (long-acting insulin) pen revealed the pen lacked an open date or the discard date. On 04/21/26 at 09:51 AM, Licensed Nurse (LN) G reported that all insulin pens should be labeled with an opened date and a discard date.On 04/22/26 at 01:15 PM, Administrative Nurse E reported he expected all insulin pens to be labeled with the date it was opened and a discard date. The facility's policy Medication Administration, dated 08/23, documented insulin vials may be kept at room temperature in the patient's medication drawer. Date the vial when it is opened. Insulin is outdated 28 days after being opened.
- Potential for harm · D2026-04-22 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure Resident (R) 1 received the opportunity to participate in the care planning process when staff failed to invite R1, or their responsible party to care plan meetings. Findings included:- R1's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and displaced intertrochanteric fracture of right femur (broken bone outside the hip joint). R1's admission Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. R1's MDS documented R1 required moderate assistance with activities of daily living (ADLs) and touching assistance with bed mobility and transfers. R1's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 04/14/26, documented R1 had a left arm sling, right hip fracture, and falls.R1's Care Plan, dated 04/01/26,…
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 · D2026-04-22 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for Resident (R) 10 and R3.Findings included:- R10's Electronic Medical Record (EMR) documented R10 discharged home on [DATE]. R3's EMR documented R3 discharged home on [DATE].The facility was unable to provide evidence that the facility notified the LTCO of the residents' transfer/discharge from the facility.On 04/22/26 at 01:00 PM, Administrative Nurse E reported that the facility did not notify the LTCO when a resident was transferred/discharged . The facility did not provide an Ombudsman Notification policy.
- Potential for harm · D2026-04-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 Based on observation, interview, and record review, the facility failed to adequately assess Resident (R) 11's present-on -admission pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) at the time of admission and failed to ensure wound treatment orders were obtained and treatments provided.Findings included:- R11's Electronic Medical Record (EMR) revealed diagnoses of weakness, frailty, and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid).R11's EMR revealed no admission [NAME] Data Set (MDS) was completed since R11 admitted on [DATE].R11's Base Line Care Plan, dated 04/17/26, instructed staff to keep skin dry and intact, avoid pressure on skin, and avoid shearing/friction. Collaborate with Dietitian for R11's dietary needs.R11's Physician Orders instructed staff to apply lanolin ointment (moisturize and protect dry, scaly, 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.
- Potential for harm · F2024-06-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of four residents. Based on observation, interview, and record review, the facility failed to serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne illness. This deficient practice had the potential to negatively affect all residents in the facility. Findings included: - During observation of the noon meal service in the kitchen on 06/11/24 at 11:35 AM, Dietary Staff G removed a thermometer probe from the sheath in her sleeve pocket and placed the tip of the thermometer into a steak product without sanitizing the thermometer probe. On 06/11/24 at 11:35 AM, Dietary Staff G stated that the thermometer had been sanitized that morning and that the thermometer was stowed in a sheath in her sleeve pocket. On 06/11/24 at 11:36 AM, Dietary Staff G inspected the sheath of the thermometer probe in her sleeve pocket under the direction of Dietary Manager F and surveyor and revealed that the sheath was not fully enclosed and had a pre-manufactured hole in the end. Dietary Staff G stated that…
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 · F2024-06-12 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of four residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - Initial tour of the kitchen facilities on 06/10/24 at 02:00 PM with Dietary Manager F, revealed that the outside dumpster area contained eight double-lidded dumpsters and that four of the eight dumpster lids were in the open position. On 06/10/24 at 02:10 PM, Dietary Manager F stated that the dumpsters were shared between the facility and the attached hospital and that the lids remaining open was an on-going problem and stated that the attached hospital's environmental services staff routinely left the lids open on the trash dumpsters. Additionally stated that the lids to the dumpsters were to be closed at all times. On 06/10/24 at 05:30 PM, observation of two of the eight dumpsters had lids stowed in the open position. On 06/11/24 at 07:20 AM, observation of one of the eight dumpsters had lids stowed in the open…
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 before2024-06-12 · 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 reported a census of four residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 59 dates between 01/01/23 and 12/31/23. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 3 2023 (April 1-June 31) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 04/05, Wednesday (WE), On 04/08, Saturday (SA), On 04/12, WE, On 04/22, SA, On 04/28, Friday (FR), On 04/29, SA, On 05/06, SA, On 05/13, SA, On 05/29, Monday (MO), On 06/15, Thursday (TH), Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · F2024-06-12 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure 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 — an excerpt from the official record, may be distressing
The facility reported a census of four residents. Based on interview and record review, the facility failed to ensure five of five Certified Nurse Aides (CNAs) reviewed had the required in-service education which included the abuse, neglect and exploitation (ANE) and one CNA which also lacked dementia management training. This deficient practice placed the residents at risk for inadequate care. Findings included: - Review of five staff personnel files/in-service training records revealed all five CNA staff, (CNA H, CNA I, CNA J, CNA K and CNA L) lacked abuse, neglect and exploitation (ANE) training as required. Additionally, CNA J lacked training related to the care of residents with dementia (a progressive mental disorder characterized by failing memory, confusion) as required. On 06/11/24 at 02:33 PM, Administrative Staff M confirmed the above information and revealed that she was unaware of the regulatory requirement for required continuing education topics. On 06/13/24 at 11:23 AM, Administrative Nurse B confirmed the training records for CNA H, CNA I, CNA J, CNA K and CNA L…
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 · D2024-06-12 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of four residents with four residents sampled. Based on interview and record review, the facility failed to accurately complete a comprehensive assessment on the Minimum Data Set, for resident (R)7 within the time frame of 14 calendar days. Findings included: - Resident (R)7's Electronic Health Record (EHR) revealed a diagnosis of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), diabetic left foot ulcer (is a skin sore that often occurs on the feet, toes, or legs in people with diabetes) and pain. The EHR lacked an admission Minimum Data Set (MDS). R7 was admitted on [DATE]. Review of the 05/26/24 five day MDS, documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. No depression, no behaviors. R7 was independent with ADL's (activities of daily living such as walking, grooming, toileting, dressing and eating). On 06/10/24 the Care Plan dated 05/22/24 documented:…
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 before2024-06-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of four residents. The sample included four residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to hand hygiene by lack of hand hygiene during R7's peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period of time) to prevent the spread of infection. Findings included: - On 06/11/24 at 10:38 AM, Licensed Nurse (LN) N stood at R7's door with gloves on her hands, handled a wound vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) and the bag for the wound vac. LN N proceeded to place wound vac and bag down on a counter, and applied a personal protective gown to herself and left the gloves on her hands. LN N then explained to R7 that she was there to remove his peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period of time). LN N removed the dressing from…
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 · D2024-06-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of four residents with four residents sampled. Based on interview and record review, the facility failed to provide requested vaccination to one of the residents. Resident (R) 6 requested the pneumococcal vaccine (vaccine designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]). Findings included: - Review of the Electronic Health Record (EHR) on 06/11/24 for (R)6 lacked documentation of any pneumococcal vaccine administered. A consent for pneumococcal vaccine was located in R6's paper chart, which R6 signed to receive a pneumococcal vaccine on an undated form. Review of EHR on 06/11/24 revealed an Immunization Assessment dated 06/04/24 at 12:44 PM, documented yes, that indicated the physician to be informed before discharge of patient's indication for the pneumococcal vaccine. On 06/11/24 at 10:05 AM, Administrative Nurse C stated that R6 did not receive the requested pneumococcal vaccine prior to discharge. Administrative Nurse C stated, it slipped through the cracks. On 06/11/24 at 01:00 PM,…
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 before2026-04-22 · 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
Based on observation, interview and record review, the facility failed to electronically submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) related to weekend staffing.Findings included - The PBJ Staffing Date Report revealed No RN Hours triggered four or more days within the quarter with no RN Hours. Additionally, the facility failed to have Licensed Nursing Coverage 24 hours/day for four or more days within the quarter for the following timeframes:Fiscal Year (FY) 2026, Quarter 1 2026 (October 1 - December 31). FY Quarter 3 2025 (April 1 - June 30). Review of the Nursing schedule for 04/01/25 - 06/30/25 and 10/01/25- 12/31/25 revealed the facility had 24 hours/day of Licensed Nursing Coverage when the Skilled Nursing Unit was open. On 04/22/26 at 01:33PM, Administrative Nurse D and Administrative Nurse E confirmed the inaccuracies of the PBJ data for the quarters identified above and reported that neither of them had looked at the PBJ reports prior to today and were unsure why the PBJ reports were submitted inaccurately.On 04/22/26 at 02:00 PM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CAIN, SANDRA | Individual | W-2 MANAGING EMPLOYEE | since 05/01/2021 |
| COWAN, MARK | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 05/01/2015 |
| MOREE, KEELEY | Individual | W-2 MANAGING EMPLOYEE | since 06/01/2019 |
| WILLIAMS, AMBER | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | since 07/01/1997 |
| KNUDSEN, DENNIS | Individual | CORPORATE DIRECTOR | since 04/01/2022 |
| LARA, JOSE | Individual | CORPORATE DIRECTOR | since 04/01/2021 |
| LOVE, IVANHOE | Individual | CORPORATE DIRECTOR | since 03/18/2018 |
| MCKEE, TONY | Individual | CORPORATE DIRECTOR | since 04/01/2022 |
| NOBLEJAS, MARIA | Individual | CORPORATE DIRECTOR | since 07/01/2021 |
| SANDER, DENNIS | Individual | CORPORATE DIRECTOR | since 04/01/2015 |
| WEST, JOHN | Individual | CORPORATE DIRECTOR | since 04/01/2022 |
CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
What families pay in KS
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Kansas Medicaid page for homes that do.
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 175163. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, 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.