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Meadowlark Hills

2121 Meadowlark Road, Manhattan, KS 66502 · Non profit - Corporation · 134 certified beds · (785) 537-4610 Medicare & Medicaid certified

Call the home — (785) 537-4610 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Aug 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,278 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Aug 2024
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-02-03)

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.

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

Location & what’s nearby

Urgent care / clinic
1325 Research Park Dr · (785) 537-2651 · Call to confirm hours
Pharmacy
Grocery
730 Allen Rd · (478) 219-2485 · Call to confirm hours
Park
BLUEMONT SCENIC Dr · Typically dawn to dusk
Place of worship
2121 Blue Hills Rd · (785) 539-8691

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 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.2%17.9%15.4%typical
Long-stay residents who lose too much weight6.5%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder1.1%1.6%0.9%worse
Long-stay residents with a urinary tract infection3.1%2.9%2.0%worse
Long-stay residents with depressive symptoms0.3%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.1%4.3%3.3%typical
Long-stay residents whose ability to walk worsened14.5%16.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication19.6%23.2%18.9%typical
Long-stay residents given the seasonal flu vaccine99.1%95.5%95.3%typical
Long-stay residents with pressure ulcers4.2%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control22.0%22.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table11.6%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine94.7%73.8%79.4%better
Short-stay residents rehospitalized after admission18.9%22.4%22.6%better
Short-stay residents with an outpatient ER visit5.2%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.631.801.67typical
Long-stay outpatient ER visits per 1,000 resident days1.162.131.80better

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

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

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

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

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

60.2% 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 167 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.2%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
68.6%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 68.6% 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 118 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF60.2%CMS range 53.3–66.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 5.5–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge68.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge68.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.5%CMS range 3.0–9.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.08
RN hours/ resident / day
0.61
LPN hours/ resident / day
2.82
Aide hours/ resident / day
4.51
Total nurse hours/ resident / day
0.82
RN hoursweekends
48.8%
Total nursing turnover
21.2%
RN turnover

How full it usually is: this home is certified for 134 beds and averages 123.7 residents a day — about 92% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.82 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.19 hrs/resident/day on weekends vs 4.65 on weekdays — 10% thinner on weekends. RN hours go from 1.19 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-04-09)
14
at the previous standard inspection (2023-07-19)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2025-02-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 119 residents, with three residents sampled. Based on record review and interview, the facility failed to ensure Resident (R) 1 was secured with the safety belt in a mechanical spa lift chair, during a transfer out of a spa tub. This deficient practice resulted in R1 falling from the spa lift chair and R1 sustained a fractured (broken bone) right femur (thigh bone). Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), dementia (a progressive mental disorder characterized by failing memory and confusion) with other behavioral issues and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), difficulty in walking, compression fracture of first lumbar (lower back) vertebra (bone of the spinal column), presence of right artificial knee joint, periprosthetic fracture around internal…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2025-04-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 117 residents. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one of one facility kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 04/07/25 at 08:35 AM, an initial tour of the Long-Term Care (LTC) main kitchen revealed the following: 1. The shelving unit for clean pans had 4 shelves and the bottom shelf had rust with sheet pans stored on it. All four shelves had chipped blue paint. The clean steam table pans had dried, stuck on pieces of the plastic wrap used when the food was first cooked, and placed on the steam table for a meal. 2. The single food prep table bottom shelf had containers on it with numerous dried food crumbs. The bottom shelf of the double food prep table had numerous crumbs and crumbs on the stored cooking equipment. 3. The flour and sugar bins both had scoops in the bins. 4. A metal knife holder on the side of the brown…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-09 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop 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 had a census of 117 residents. The sample included 25 residents, with five reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidelines from the Centers for Disease Control and Prevention (CDC) when they failed to offer and administer or obtain an informed declination, or a physician-documented contraindication for Resident (R) 36, R63, R70, R80, and R85, pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease. Findings included: - Review of R36, R63, R70, R80, and R85's clinical medical records lacked evidence the facility and/or the resident representative received or signed consent or informed declination for the current pneumococcal vaccine PCV20. The records lacked evidence of a physician-documented contraindication for use of the vaccine. On 04/08/25…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0625 — isolated
    Notify 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 117 residents. The sample included 25 residents, with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 35 and R5 with written information regarding the facility bed hold policy when she was transferred to the hospital. This placed the residents at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R35's Electronic Health Record (EHR) revealed diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and celiac disease (a chronic autoimmune disorder where the body's immune system reacts abnormally to gluten- a protein found in wheat, rye, and barley). R35's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R35…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 117 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to include a hospice (a program that gives special care to people who are near the end of life) service visit frequency, medications, medical equipment, and the resident representative's preference for Resident (R) 69. This deficient practice placed the resident at risk of not receiving resident-directed end-of-life care. Findings included: - R69's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), dysphagia (swallowing difficulty) following nontraumatic intracranial hemorrhage (a brain bleed), hemiplegia (swallowing difficulty) and hemiparesis (muscular weakness of one half of the body) affecting left non-dominant side, lack of coordination, need for assistance with personal cares, and dementia (a progressive mental disorder characterized by failing memory 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 117 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to maintain standardized infection control practices during a dressing change for Resident (R) 26. This placed the resident at increased risk of wound infection. Findings included: - R26's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) with other circulatory complications, cutaneous (related skin) abscess (cavity containing pus and surrounded by inflamed tissue) of buttock, Parkinson's (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) disease, non-pressure chronic ulcer of buttock with fat layer exposed, local infection of the skin and subcutaneous (beneath the skin) tissue, and pressure ulcer (localized injury to the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-06 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 121 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from misappropriation when Licensed Nurse (LN) G, on 02/11/24 at 06:57 PM, emptied R1's promethazine (medication used to prevent and treat nausea and vomiting) with codeine (narcotic pain medication) liquid into a water bottle and put it in her purse then left the facility with it. This deficient practice placed R1 at risk for missed medications and further misappropriation of medications. Findings included: - R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of chronic pain, shortness of breath, and constipation. The admission Minimum Data Set (MDS) dated 01/23/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. The Quarterly MDS dated 07/24/24, documented R1 had a BIMS score of 11 which indicated…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 120 residents. Based on observation, interview, and record review the facility failed to serve food in a sanitary manner for residents in one of seven households. This deficient practice placed the 22 residents of the household at risk for food borne illness. Findings included: - On 07/17/23 at 11:37 AM, observation revealed Certified Nurse Aide (CNA)/Homemaker Staff P preparing and serving meals to the residents. Continued observation during the lunch meal revealed the homemaker did the following without washing her hands: Removed soiled dishware from a table and rinsed off the resident's used plate. Removed a bag of chicken breast strips from the freezer and used her bare hand to place two in the air fryer. Handled clean silverware to put in a drawer. Wiped her hands on her apron several times throughout the meal. Retrieved a bowl out of the upper cupboard with her finger inside then filled it with food for a resident. Handled two soiled plates with soiled napkins and rinsed them. Retrieved another bowl out of the cupboard and filled it with fruit…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 - R106's Electronic Medical record (EMR) documented diagnoses of congestive heart failure (CHF-a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), end stage renal disease (ESRD-a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for dialysis or a transplant), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R106 required supervision for dressing and was independent with all other activities of daily living. The Nutrition Care Plan, dated 04/25/23, directed staff to obtain the resident's weight on non-dialysis (procedure where impurities or wastes were removed from the blood) days. The Physician Order, dated 06/23/22, for a diagnosis of CHF, directed staff to obtain weight on non-dialysis days upon rising; call the physician to notify them of 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 120 residents. The sample included 24 residents. Based on observation, recrod review, and interview, the facility failed to provide a clean environment for two sampled residents, Resident (R) 66 and R7, who had wheelchairs which were soiled with dried food particles. This placed the affected residents at risk for impaired comfort and/or dignity. Findings included: - On 7/17/23 at 08:50 AM, observation revealed R66's wheelchair had dried food particles and stains on the sides of her seat that looked to be from several food services. On 07/17/23 at 09:00 AM, observation revealed R7's high back wheelchair had dried fluid stains in the center of his wheelchair cushion. On 07/18/23 at 07:30 AM, observation revealed R7's high back wheelchair continued to have the same dried fluid stains on his wheelchair. On 7/18/23 at 08:30 AM, observation revealed R66's wheelchair continued to have the same dried food particles and stains on the sides of her seat. On 07/18/23 at 09:30 AM, Licensed Nurse (LN) G stated the wheelchair's were cleaned weekly on night shift. LN G…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0623 — isolated
    Provide 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 120 residents. The sample included 24 residents. Based on observation, interview, and record review, the facility failed to notify the Long-Term Care Ombudsman (LTCO) when Resident(R) 53 discharged to the hospital. This placed the resident at risk for decreased autonomy and quality of life. Findings included: - R53's Physician Order Sheet (POS), documented diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and heart failure. R53's Quarterly Minimum Data Set (MDS), dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of one staff with most activities of daily living (ADLs). The ADL Care Plan, dated 04/28/23 documented the resident had an ADL self-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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2023-07-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 120 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to develop an individualized comprehensive person-centered care plan related to Resident (R)26's aspiration (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) risk and R71's dialysis (procedure of removing extra fluid and waste product from the blood) treatment which placed R26 and R71 at risk for unmet care needs. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of gastro-esophageal reflux disease (GERD- backflow of stomach contents to the esophagus), obstructive sleep apnea (absence of breathing), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 120 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent skin tears for one sampled resident, Resident (R) 66, who received skin tears during cares. This placed R66 at risk for further injury due to uncommunicated and/or unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R66 documented diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning), hypertension (high blood pressure), anxiety (a feeling of worry, nervousness, or unease), and depression (abnormal emotional state characterized by exaggerated of sadness, worthlessness, emptiness, and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R66 had severely impaired cognition and required extensive assistance of one staff for dressing, toileting, and personal hygiene. R66 required limited assistance of one…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility has a census of 120 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to identify and respond to daily weight variances for Resident (R) 55 and R106, and failed to identify implement preventative measures to prevent skin tears for R66. This placed the residents at risk for physical complications, decline and pain. Findings included: - The Electronic Medical Record for R55 documented diagnoses of hypertension (high blood pressure), chronic kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), and congestive heart failure (CHF-a condition in which the heart doesn't pump blood as well as it should). R55's Significant Change Minimum Data Set (MDS), dated [DATE], documented R55 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation, and supervision and set-up assistance for eating. The MDS recroded R55 had no weight loss or gain. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 120 residents. The sample included 24 residents with 14 residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment for Resident (R)8 who fell from her electric lift recliner during a self-transfer, and R16 who had multiple falls with staff in which the facility failed to identify the need for increased staff assistance. These deficient practices placed the residents at risk for falls and related injuries. Findings included: - R8's Electronic Medical Record (EMR) recorded diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R8's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 120 residents. The sample included 24 residents, with two reviewed for hydration. Based on observation, record review, and interview, the facility failed to monitor hydration status for Resident (R) 55, who was on a physician ordered fluid restriction. This placed the residents at risk for dehydration or fluid overload. Findings included: - The Electronic Medical Record for R55 documented diagnoses of hypertension (high blood pressure), chronic kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), and congestive heart failure (a condition in which the heart doesn't pump blood as well as it should). R55's Significant Change Minimum Data Set (MDS), dated [DATE], documented R55 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation, and supervision and set-up assistance for eating. The Quarterly MDS, dated 06/14/23, documented R55 had intact cognition and required limited assistance 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 120 residents. The sample included 24 residents with two reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing fluid restriction implementation for Resident (R)71, who received dialysis treatment. This placed the resident at risk for complications and health decline. Findings included: - R71's Electronic Medical Record (EMR) recorded diagnoses of end stage renal disease (decline in kidney function) and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R71's admission Minimum Data Set (MDS), dated 06/14/23, recorded R71 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded she was independent with bed mobility, dressing, toileting, and personal hygiene. The MDS further recorded R71 received dialysis treatment. The R71's EMR lacked a dialysis…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 120 resident. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to ensure a system to review and respond to the Consultant Pharmacist's (CP) repeated recommendation to complete an Abnormal Involuntary Movement Scale (AIMS) for Resident (R) 84 and R66 who received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication which placed the R84 and R66 at risk of adverse side effects associated with psycotropic (alters mood or thought) medications. Findings included: - R84's Electronic Medical Record (EMR) documented diagnoses of hypertension (elevated blood pressure), dysphagia (swallowing difficulty), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion) with agitation, and unspecified psychosis (any major…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 120 residents. The sample included 24 residents. Based on observation, record review and interview the facility failed to hold diuretic medications multiple times for blood pressure readings outside of physician ordered parameters for Resident (R)26, which placed the resident at risk for continued low blood pressure. Findings included: - R26's Electronic Medical Record (EMR) documented diagnoses of gastro-esophageal reflux disease (GERD- backflow of stomach contents to the esophagus), obstructive sleep apnea (absence of breathing), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), personal history 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 120 resident. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) for Resident (R) 84 and R66 who received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication which placed the R84 and R66 at risk of adverse side effects of psychotropic (alters mood or thoughts) medications. Findings included: - R84's Electronic Medical Record (EMR) documented diagnoses of hypertension(elevated blood pressure), dysphagia (swallowing difficulty), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion) with agitation, and unspecified psychosis (any major mental disorder characterized by a gross impairment in reality testing) not due to a substance or known…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility had a census of 120 residents and identified four medication rooms. Based on observation, recrod review, and interview the facility failed to ensure expired medications were disposed of in a timely manner. This deficient practice placed residents at risk to receive ineffective medication. Findings included; - On 07/12/23 at 10:06 AM, observation in one of four facility medication rooms revealed one dose of influenza (flu) vaccine with an expiration date of 05/12/23 and six doses of the influenza vaccine with an expiration date of 06/30/23. On 07/13/23 at 10:06 AM, Licensed Nurse (LN) K verified the vaccines were expired and should have been disposed of. The facility's Storage of Medications in the Medication Room Procedure, did not include direction for expired medications. The facility failed to dispose of expired vaccine doses in a timely manner, placing residents at risk to receive ineffective vaccines.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 127 residents. The sample included 25 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to notify the physician of Resident (R) 47's heart medications held numerous times due to blood pressure or heart rate below physician ordered parameters, and R28's blood pressures out of physician ordered parameters. Findings included: - The Annual Minimum Data Set (MDS), dated [DATE], recorded R47 had a Brief Interview for Mental Status (BIMS) score of four (severe cognitive impairment), and disruptive behaviors. The MDS recorded R47 required limited staff assistance with most activities of daily living (ADLs), and had diagnoses of atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), hypertension (elevated blood pressure that can cause heart disease and stroke), congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should) and coronary…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 127 residents. Based on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for the residents that resided in two of the seven households in the facility. Findings included: - On 10/07/21 at 08:30 AM, the initial tour revealed the following: [NAME] Household; R119's carpet area with a large stain on the entrance of the room approximately 12 inches x 18 inches, and numerous circular brownish black stains approximately 1-inch in circumference extending from the entrance of the room to the other side of the room. R38's bed B carpet area with numerous reddish brown stains in front of the wheelchair approximately 4 inches x 2 inches, and brownish black 1 inch x 0.5 inch circular stains in front of the resident's recliner. R98's carpet area with small brownish black spots, 1 inch x 0.5 inch extending from the hall -door entrance to bed B, brownish black stains and a black stain in front of the TV approximately 1…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-13 · tag F0623 — isolated
    Provide 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 127 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to notify the Ombudsman for one sampled resident discharged to the hospital, Resident (R) 126. Findings included: - R126's Physician Order Sheet (POS), dated 05/21/21, documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), cerebral vascular accident (CVA-stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The admission Minimum Data Set (MDS), dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of one staff with most activities of daily…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 127 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to update and revise the care plan for one of three residents reviewed for pressure ulcers, Resident (R) 63. Findings included: - The Physician Order Sheet dated 10/06/21 recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, and chronic peripheral venous insufficiency (abnormal condition affecting the blood vessels that affects blood flow to the extremities). R63's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment revealed the resident required limited assistance of one staff for bed mobility, personal hygiene, and limited assistance of two staff for transfers. The MDS further documented the resident had one Stage 3 (full thickness skin loss potentially extending…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 127 residents. The sample included 25 residents with one reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to initiate interventions according to the standards of care to prevent the development of heel pressure ulcers (localized injury to the skin and/or underlying tissue usually over a boney prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 63 who was at risk for pressure ulcers. Findings included: - The Physician Order Sheet dated 10/06/21 recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, and chronic peripheral venous insufficiency (abnormal condition affecting the blood vessels that affects blood flow to the extremities). R63's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 127 residents. The sample included 25 residents with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision and assistance to prevent accidents for one sampled resident, Resident (R) 28. Findings included: - R28's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, and required extensive assistance of two staff for bed mobility, transfers, toileting, unsteady balance, no upper or lower functional impairment, and had one injury fall since prior assessment. The Fall Care Assessment (CAA), dated 10/29/20, documented the resident had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and was admitted to a memory secured household to receive assistance with activities of daily living (ADLs) and behavior management. The Fall Risk Assessments, dated 07/09/21 and 10/11/21, documented the resident a high risk for fall.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-13 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 127 residents. The sample included 25 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility's consultant pharmacist failed to notify the Director of Nursing, medical director, or physician the lack of a stop date for Resident (R) 47's PRN psychotropic medication, medications held numerous times due to blood pressure or heart rate below physician ordered parameters, and medications administered when blood pressure or heart rate were below physician ordered parameters. The facility's consultant pharmacist also failed to address the lack of physician notification for R28's blood pressures out of physician ordered parameters. Findings included: - The Annual Minimum Data Set (MDS), dated [DATE], recorded R47 had a Brief Interview for Mental Status (BIMS) score of four (severe cognitive impairment), and disruptive behaviors. The MDS recorded R47 required limited staff assistance with most activities of daily living (ADLs),…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-13 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 127 residents. The sample included 25 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to hold medications when blood pressure and/or pulse were below physician ordered parameters for one sampled resident, Resident (R) 47. Findings included: - The Annual Minimum Data Set (MDS), dated [DATE], recorded R47 had a Brief Interview for Mental Status (BIMS) score of four (severe cognitive impairment), and disruptive behaviors. The MDS recorded R47 required limited staff assistance with most activities of daily living (ADLs), and had diagnoses of atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), hypertension (elevated blood pressure that can cause heart disease and stroke), congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should) and coronary artery disease (narrowing of arteries that limits blood flow to the heart). The…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 127 residents. The sample included 25 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a stop date for a PRN (as needed) psychotropic medication (medications that affect a person's mental state) for one of five sampled residents, Resident (R) 47. Findings included: - The Annual Minimum Data Set (MDS), dated [DATE], recorded R47 had a Brief Interview for Mental Status (BIMS) score of four (severe cognitive impairment), and disruptive behaviors. The MDS recorded R47 required limited staff assistance with most activities of daily living (ADLs), and received antipsychotic (class of medication used to treat behavioral and emotional mental conditions) and antidepressant medications (class of medication used to treat mood disorders and relieve symptoms of exaggerated feelings of sadness, worthlessness and emptiness) seven days a week. The Mood and Behavior Care Plan, dated 07/29/21, directed staff 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-02-03

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

Who owns this facility

Owner / managerTypeRoleSince
BAKER, LONNIEIndividualW-2 MANAGING EMPLOYEEsince 06/30/2014
NELSON, CHRISTOPHERIndividualCORPORATE DIRECTORsince 06/30/2014
MANHATTAN RETIREMENT FOUNDATION INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/27/1988

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$19.1M
Net patient revenuemost recent cost report
-66.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 28%Medicare 19%Other / private 53%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$515per resident / day
operating cost
$15,661per month
≈ monthly operating cost
$309per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175174. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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