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St Luke Living Center

535 South Freeborn, Marion, KS 66861 · Government - Hospital district · 32 certified beds · (620) 382-2177 Medicaid only — no Medicare

Call the home — (620) 382-2177 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Oct 2025
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — 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.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
537 S Freeborn St · (620) 382-3722 · Call to confirm hours
Pharmacy
217 E Main St · (620) 382-2135 · Call to confirm hours
Grocery
1121 E Main St · (620) 382-2985 · Call to confirm hours
Park
Main @ Elm · (202) 690-5185 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
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 increased21.4%17.9%15.4%worse
Long-stay residents who lose too much weight6.0%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection2.3%2.9%2.0%worse
Long-stay residents with depressive symptoms9.5%6.5%6.5%worse
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 injury0.0%4.3%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened18.1%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication25.9%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers5.7%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control22.1%22.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table26.5%18.1%17.1%worse
Long-stay hospitalizations per 1,000 resident days0.001.801.67better
Long-stay outpatient ER visits per 1,000 resident days4.782.131.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

Staffing

1.08
RN hours/ resident / day
0.32
LPN hours/ resident / day
2.79
Aide hours/ resident / day
4.19
Total nurse hours/ resident / day
0.75
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 32 beds and averages 29.0 residents a day — about 91% occupied, or roughly 3 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 4.19 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 2.79 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.66 hrs/resident/day on weekends vs 4.40 on weekdays — 17% thinner on weekends. RN hours go from 1.21 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

7
deficiencies at the latest standard inspection (2025-10-08)
11
at the previous standard inspection (2024-02-22)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Ecited before2025-10-08 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 26 residents. The sample included 12 residents. Based on interviews, observation, and record review, the facility failed to ensure a safe, clean home-like environment in all areas of the facility including the resident rooms. Findings included:- Observed on 10/06/25 at 10:56 AM, several areas of Resident (R) 1's room walls had missing paint with exposed sheetrock. The bathroom door had multiple areas of missing paint with exposed wood and the metal door frame to the bathroom had missing paint with exposed metal.Observed on 10/06/25 at 11:28 AM, multiple areas on walls in R17's room had chipped and missing paint with exposed sheetrock. The bathroom door had paint missing in multiple areas with exposed wood and the bathroom door frame had missing paint with exposed metal.Observed on 10/06/25 at 11:36 AM, R2's bathroom door had multiple areas with exposed wood and the door frame had missing paint with exposed metal.Observed on 10/06/25 at 11:48 AM, R19's bathroom door had multiple…

    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 · D2025-10-08 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 26 residents. The sample included 13 residents with five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to inform R18 or her representative about the risk and benefits of taking an antianxiety (a class of medications that calm and relax people).Findings included:- R18's Electronic Medical Record (EMR) revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), psychotic disorder (a type of mental health illness characterized by a dissociation from reality, often involving symptoms such as delusions and hallucinations), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R18's 07/09/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of four, indicating severely impaired cognition. The MDS documented R18 had no delusions, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-08 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 26 residents. The sample included 13 residents with five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to attempt a gradual dose reduction (GDR) for Resident R)18's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), medication. Findings included:- R18's Electronic Medical Record (EMR) revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), psychotic disorder (a type of mental health illness characterized by a dissociation from reality, often involving symptoms such as delusions and hallucinations), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R18's 07/09/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of four, indicating severely impaired 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-08 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 26 residents. The sample included 13 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 6 a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. The facility also failed to provide R6 or the responsible party with a bed hold. Findings included:- R6's Electronic Medical Record (EMR) revealed a diagnosis of heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively enough to meet the body's needs) and dementia (a progressive mental disorder characterized by failing memory and confusion).R6's EMR documented a Health Status Note dated 09/07/25 at 07:57 AM that documented R6 was short of breath with walking to the bathroom. R6 had wheezing and diminished breath sounds.R6's Health Status Note dated 09/07/25 at 11:05 AM, documented R6 was admitted to the hospital for observation. The hospital planned to take fluid off.R6's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-08 · tag F0655 — isolated
    Create 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 The facility identified a census of 26 residents. The sample included 13 residents with two sampled for baseline care plan. Based on observation, interview, and record review, the facility failed to complete a baseline care plan for Resident (R) 29.Findings included:- R29's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion), failure to thrive, hypertension (HTN-elevated blood pressure), and atrial fibrillation (rapid, irregular heartbeat).R29 admitted on [DATE] so the 10/03/25 admission Minimum Data Set (MDS), was not completed.R29's Baseline Care Plan dated 09/25/25, was unsigned by R29 or his responsible party. It documented R29 was a full code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest). It did not have the fall risk section completed. R29's Baseline Care Plan documented he had a behavior of wandering, including a previous incident of wandering outside 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-08 · 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

    The facility reported a census of 26 residents. The sample included 12 residents. Based on interviews, record reviews and observation, the facility staff failed to implement adequate and acceptable infection control practices when staff did not disinfect a glucometer (an instrument used to calculate blood glucose) after use.Findings included:- Observed on 10/07/25 at 11:22 AM, Licensed Nurse (LN) G perform a blood glucose check on Resident (R) 2 after performing hand hygiene and donning gloves. Upon completion of the blood glucose check LN G returned to the nurse's office and did not clean or disinfect the glucometer.On 10/07/25 at 11:30 AM, LN G verified that she did not clean the glucometer and further stated that she did not usually clean it unless there was blood on it, or it was dirty.On 10/08/25 at 11:44 AM, Administrative Nurse A stated that the facility educated staff on measuring blood glucose using glucometers every year as part of the yearly competencies, and she expected staff to clean and disinfect the glucometers after each use.The undated facility Infection Control…

    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 · Fcited before2024-02-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents. Findings included: - Observation on 02/21/24 at 01:30 PM, during the environmental tour with Dietary Staff CC and Administrative Staff A, revealed the following areas of concern: 1. The food preparation and serving areas contained 18 approximately two feet by three-foot ceiling tiles which contained black dust like substances and grime. Several tiles contained brown discolorations resembling handprints. 2. The ceiling light in the food preparation area contained a black dust like substance and white dust like substance. The ceiling light in the kitchen entrance area also contained black and white dust like substances. 3. The front two stove vents contained an accumulation of grime. 4. Three large cookie sheets contained an accumulation of a black substance around the perimeter and extending into the mid area. 5. Two small skillets contained scratches…

    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 · F2024-02-22 · tag F0851 — widespread
    Electronically 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 29 residents. Based on 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 Licensed Nurse Coverage for 24 hours a day on 12 days during the third quarter 2023. Findings Included: - Review of the 'Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY) Quarter 3, 2023 (April 1-June 30) revealed lack of Licensed Nurse for the following 12 days: On 04/01 Saturday (SA). On 04/23 Sunday (SU). On 05/06 SA. On 05/07 SU. On 05/14 SU. On 05/27 SA. On 05/28 SU. On 06/20 SA. On 06/11 SU. On 06/17 SA. On 06/24 SA. On 06/35 SU. Review of the Staff Posting and Schedule revealed Licensed Nurse coverage for the above days. Interview, on 02/22/24 at 01:30 PM, with…

    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 · Fcited before2024-02-22 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 29 residents. Based on interview and record review, the facility failed to maintain an infection prevention and control program to proactively monitor infections in the facility to help prevent the spread among the residents of the facility. Findings included: - The facility lacked a surveillance plan for identifying, tracking, monitoring and reporting infections among residents. On 02/22/24 at 01:15 PM, Administrative Nurse D stated the facility did not currently use any criteria for tracking and trending infections. The facility lacked a policy for infection control surveillance. The facility failed to maintain an infection prevention and control program to proactively monitor infections in the facility to help prevent the spread of infections among the residents of the facility.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 29 residents with 14 residents sampled, including one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)25, while transporting the resident in a sit to stand mechanical lift from her bed to the bathroom with the blinds partially open. Findings included: - Review of Resident (R)25's electronic medical record (EMR) revealed the following diagnoses: hemiparesis/hemiplegia (weakness and paralysis on one side of the body) and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and had impairment on one side of her upper and lower extremities. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area…

    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 12 citations
  • Potential for harm · Dcited before2024-02-22 · tag F0655 — isolated
    Create 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 The facility reported a census of 29 residents, with 14 residents sampled. Based on observation, interview and record review, the facility failed to develop an individualized baseline plan of care for one Resident (R)130 regarding an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). Findings included: - Review of Resident (R)130's electronic medical record (EMR) revealed the resident admitted to the facility on [DATE] with a diagnosis of urinary retention (the inability to pass urine). Review of the resident's admitting orders to the facility revealed the following physician's order: Urinary catheter, ordered 02/08/24. On 02/21/24 at 09:02 AM, Certified Nurse Aide (CNA) O entered the resident's room to provide catheter care. On 02/21/24 at 09:06 AM, CNA O stated the resident admitted to the facility with the urinary catheter. On 02/22/24 at 09:15 AM, Licensed Nurse (LN) G stated staff would look at the resident's care plan in order to find instruction on caring for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-22 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 29 residents with 14 residents included in the sample. Based on observation, record review, and interview, the facility failed to review and revise the care plans for one Resident (R)4, regarding the use of an anti-depressant (medication used to treat depression) medication. Findings included: - Review of Resident (R)4's electronic medical record (EMR) revealed a diagnosis of major depressive disorder ([MDD]major mood disorder which causes persistent feelings of sadness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severe impairment. The resident received anti-depressant medication during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/29/23, documented the resident received an anti-depressant medication for MDD. The Quarterly MDS, dated 10/18/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 29 residents with 14 selected for review, which included two residents reviewed for activities of daily living. Based on observation, interview, and record review, the facility failed to provide one Resident (R) 21, with shaving opportunities in the manner of his preference. Findings included: - Review of Resident (R)21's medical record revealed diagnoses that included unspecified dementia (progressive mental disorder characterized by failing memory, confusion) cerebral vascular accident (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), chronic kidney disease and diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. R21 had impairment in both…

    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 · D2024-02-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 29 residents with 14 residents selected for review, which included two residents reviewed for hydration. Based on observation, interview, and record review, the facility failed to provide one Resident (R) 21, with access to fresh water throughout the day. Findings included: - Review of Resident (R)21's medical record revealed diagnoses that included unspecified dementia (progressive mental disorder characterized by failing memory, confusion) cerebral vascular accident (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), chronic kidney disease and diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. R21 had impairment in both lower extremities 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-22 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 29 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)9 received antibiotics appropriately for a urinary tract infection. Findings included: - Review of Resident (R) 9's medical record, revealed diagnoses included cerebral vascular accident (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), Alzheimer's disease ((progressive mental deterioration characterized by confusion and memory failure) with dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status Score (BIMS) score of nine, which indicated moderate cognitive impairment. The resident was frequently incontinent of urine. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA)…

    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 · D2024-02-22 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 29 residents. Based on interview and record review, the facility failed to ensure one Residents (R)13 was offered the influenza vaccine. Findings included: - Review of Resident (R)13 electronic medical records (EMR) revealed she lacked the influenza vaccine. On 02/22/24 at 09:03 AM, Administrative Nurse D stated the facility failed to offer the influenza vaccine to the resident. The facility policy for Immunizations, revised 2023, included: The facility will provide education to residents regarding the health risks associated with influenza and pneumococcal pneumonia and COVID-19 and will offer ever resident the opportunity to receive immunizations unless contraindicated. The facility failed to offer the influenza vaccine to this dependent resident.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-06-21 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 19 residents. Based on interview and record review, the facility failed to provide direct care staff annual evaluations/performance reviews to determine strengths and weaknesses in providing resident care. Findings included: - Review of five Certified Nursing Assistant (CNA) personnel files revealed the following: Review of CNA M, with hire date of 07/05/19, revealed lack of an annual review. Review of CNA N, with hire date of 05/21/14, revealed lack of an annual review. Review of CNA O, with hire date of 12/18/20, revealed lack of an annual review. Review of CNA P, with hire date of 09/09/20, revealed lack of an annual review. Review of CNA Q, with hire date of 12/01/21, revealed lack of an annual review. On 06/21/22 at 10:49 AM, Administrative Staff A stated the facility did not complete individualized staff evaluations. On 06/21/22 at 10:49 AM, Administrative Nurse D stated, annual staff evaluations should be completed, but were not. The facility policy for Employee Annual…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-06-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 19 residents. Based on observation, record review and interview, the facility failed to store food under sanitary conditions to prevent the spread of food borne illnesses to residents of the facility. Findings included: - During an environmental tour on 06/20/22 at 10:00 AM, with Housekeeping/Maintenance Staff U, revealed the following concerns in the kitchenette area in the resident area on the 500 hall: 1. The resident's common microwave had a large amount of dried food on the inside. 2. The residents' refrigerator had dried food and food debris that littered the bottom shelf of the refrigerator on the bottom shelf. 3. There was a plate of raw vegetables, dated 06/13/22. 4. There was an unopened bag of kale and turnips, undated. 5. There was an unopened bag of spinach, dated 05/27/22. 6. An opened, undated bag of baby carrots, contained slime and had a strong odor. On 06/21/22 at 10:12 AM, Administrative Nurse D stated, the night shift staff were responsible for cleaning out the resident refrigerator. Any staff who put food into the refrigerator…

    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 · Ecited before2022-06-21 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 19 residents. Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in the facility, on one of three halls. Findings included: - During an environmental tour on 06/20/22 at 10:00 AM with Housekeeping/Maintenance staff U revealed the following concerns: 1. Three resident fall mats rested on their sides directly on the floor in the soiled utility room. 2. A full box of disposable briefs and a partial, opened bag of briefs rested directly on the floor in the clean utility room. On 06/21/22 at 10:12 AM, Administrative Nurse D stated, the briefs and floor mats should not rest directly on the floor. All supplies need to have a barrier from the floor. The facility lacked a policy for the storage of resident supplies. The facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for the residents of the facility, on one of three halls.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-21 · tag F0636 — isolated
    Assess 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 19 residents with eight residents included in the sample. Based on observation, interview and record review, the facility failed to complete the triggered areas of the Minimum Data Set (MDS) of the Care Area Assessment (CAA), for three residents, including Resident (R)16, regarding Cognitive Loss/Dementia, Behavioral Symptoms, Psychotropic Drug Use, Psychosocial Well-Being and Mood State, R 17, regarding Cognitive Loss/Dementia, Behavioral Symptoms, Psychosocial Well-Being, Psychotropic Drug Use and Nutritional Status, and R 19, regarding Activities of Daily Living (ADL) Functional/Rehabilitation Potential and Psychotropic Drug Use. Findings included: - The Physician Order Sheet (POS), dated 05/09/22, for Resident (R)16, documented diagnoses, which included: hypertension (HTN--elevated blood pressure), psychotic disorder (mental disorder characterized by a gross impairment in reality testing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2025-10-08 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 26 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the daily licensed and unlicensed staff actual hours.Findings included:- Daily Staffing sheets reviewed for the following dates did not list the actual hours worked, the total hours worked for nurses and CMA/CNA were listed: 08/01/25, 08/02/25, 08/03/25, 08/04/25, 08/05/25, 08/06/25, 08/07/25.Observed on 10/06/25 at 10:05 AM, the daily staffing sheet was not posted. Observed on 10/07/25 at 10:11 AM, the daily staffing sheet was posted on door frame of the nurse's office and only listed the total hours worked, the actual hours were not listed.ON 10/07/25 at 10:26 AM, Licensed Nurse (LN) G reported that the 3PM to 3AM shift was responsible for filling out the daily staffing sheets based on the weekly staffing schedule; that nurse then taped the staffing…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-02-22 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility reported a census of 29 residents. Based on interview and record review, the facility failed to post the Direct Care Staff Nursing Hours in a manner to reflect the scheduled hours and actual hours worked by staff as required. Findings included: - Review of the Direct Care Staff Nursing Hours for December 2023, January 2024, and February 2024, revealed the document lacked indication of the actual hours worked by staff at the end of the shift. Interview, on 02/22/24 at 01:30 PM, with Administrative Nurse D, revealed the night shift nurse filled in the document with the scheduled hours worked, but did not update the document upon completion of the shift to reflect the actual hours worked. The facility did not provide a policy for updating the Direct Care Staff Nursing Hours. The facility failed to update the Direct Care Staff Nursing Hours to reflect the actual hours worked by nursing staff as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

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

What families pay in KS

Paying with Medicaid

CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.

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 17A029. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-08, 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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