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McPherson Operator, LLC

1601 N Main Street, McPherson, KS 67460 · For profit - Limited Liability company · 45 certified beds · (620) 241-5360 Medicare & Medicaid certified

Call the home — (620) 241-5360 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Apr 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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 (25) — 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1101 N Main St · (620) 241-4477 · Call to confirm hours
Pharmacy
400 W 4th St · (620) 241-0022 · Call to confirm hours
Grocery
Dillons0.6 mi
1320 N Main St · (620) 241-6084 · Call to confirm hours
Park
Hess Park0.4 mi
1520 Canterbury St · (620) 245-2565 · 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 3 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 improved from 2 to 3 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 rating3★
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 increased13.2%17.9%15.4%better
Long-stay residents who lose too much weight8.5%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder0.9%1.6%0.9%typical
Long-stay residents with a urinary tract infection5.4%2.9%2.0%worse
Long-stay residents with depressive symptoms45.2%6.5%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.5%4.3%3.3%better
Long-stay residents whose ability to walk worsened15.1%16.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication26.2%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers5.3%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control23.6%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table42.1%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.4%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine86.2%73.8%79.4%typical
Short-stay residents rehospitalized after admission15.8%22.4%22.6%better
Short-stay residents with an outpatient ER visit7.5%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.981.801.67worse
Long-stay outpatient ER visits per 1,000 resident days1.032.131.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

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

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

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

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

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

65.2% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.2%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
41.7%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 41.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF65.2%CMS range 52.7–78.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.7–14.010.7%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 discharge41.7%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 discharge45.8%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 discharge41.7%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 2.7–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.57
RN hours/ resident / day
0.80
LPN hours/ resident / day
2.36
Aide hours/ resident / day
3.74
Total nurse hours/ resident / day
0.37
RN hoursweekends
42.6%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 45 beds and averages 38.3 residents a day — about 85% occupied, or roughly 7 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 is below 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 3.37 hrs/resident/day on weekends vs 3.88 on weekdays — 13% thinner on weekends. RN hours go from 0.66 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% 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

6
deficiencies at the latest standard inspection (2025-04-23)
13
at the previous standard inspection (2023-08-07)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2025-04-23 · 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 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when staff left an unlocked shower door open on Country Hall and Resident (R) 12 entered, fell, and sustained a fractured wrist. This placed the residents at risk for preventable accidents or injuries. Findings included: - R12's Electronic Medical Record (EMR) recorded diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and muscle weakness. R12's Quarterly…

    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 before2025-04-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to measure and record food temperatures for food items at mealtime and the daily refrigerator and freezer temperatures for the evening shift. The facility further failed to record the chemical Parts Per Million (PPM) of the sanitizing solution (Chemical PPM- 50-400) on the Sanitizer Bucket Log three times a day. This placed the residents at risk for food borne illnesses. Findings included: - On 04/21/25 at 07:45 AM, during the initial kitchen tour, the daily temperature logs for the refrigerator and freezer for April 2025, lacked documentation of the temperatures were taken during the following days on the evening shift: 04/10/25, 04/11/25, 04/12/25, 04/13/25, 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/19/25, and 04/20/25 On 04/21/25 at 07:50 AM, Dietary Staff BB verified the lack of documentation and stated the temperatures of the refrigerator and freezer were supposed to be taken daily in the morning and in the evening. On 04/22/25 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-23 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 42 residents. Based on interviews and record review, the facility failed to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the affected residents at risk for abuse, neglect, misappropriation, or mistreatment. Findings included: - On 04/22/25 at 03:40 PM review of staffing for background checks was completed for facility Staff. Upon request and review, the facility was unable to provide evidence a criminal background check was completed for Certified Medication Aide (CMA) R, who had worked at the facility since his hire date of 08/29/24. On 04/22/25 at 04:30 PM, Administrative Staff A stated the business manager would obtain criminal background/record checks on all employees prior to the employee working at the facility. Administrative Staff A verified facility staff could not find a criminal record check…

    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 · Dcited before2025-04-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 42 residents. The sample included 12 residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility staff failed to immediately report to the nurse in charge an incident between Resident (R) 12 and R17. This placed R17 at risk for ongoing abuse and/or mistreatment and a lack of adequate supervision. Findings included: - R17's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and muscle weakness. R17's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R17 had moderately impaired cognitive function. The MDS recorded R17 required extensive assistance with transfers, activities of daily living (ADL), and propelled in a wheelchair. The MDS documented the resident received Hospice services. The MDS documented the resident had no behaviors…

    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 · D2025-04-23 · 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 42 residents. The sample included 12 residents, with two reviewed for hospitalizations. Based on observation, record review, and interview, the facility failed to provide one resident, Resident (R) 27, with written information regarding the facility's bed hold policy when R27 was transferred to the hospital. This placed the resident at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - The Electronic Medical Record (EMR) for R27 documented diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow), chronic kidney disease (moderate decline in kidney function) stage 3, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), hypertension (high blood pressure), lymphedema (swelling…

    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 · D2025-04-23 · 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 42 residents. The sample included 12 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 17. This placed the residents at risk for inadequate end-of-life care. Findings included: - R17's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and muscle weakness. R17's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R17 had moderately impaired cognition. The MDS recorded she required extensive staff assistance with transfers 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 · Fcited before2023-08-07 · 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 39 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to prepare and serve food in a sanitary condition for the 39 resident's who resided in the facility placing them at risk for food borne illness. Findings included: - On 08/01/23 at 08:15 AM, observation revealed the following: The large silver freezer, pulled out approximately 12 inches from the wall with multiple dead bugs, leaves, and dirt on the floor. The wall beside the large silver refrigerator had dried red liquid splattered from the floor up to the ceiling. Two dirty rags were on the floor next to a cart that had dirty rags. The inside of the door of the microwave had dried food debris. The small toaster had dried food debris on the sides of the toaster. On 08/01/23 at 12:00 PM, observation revealed three plates with the noon meal of two soft tacos, Spanish rice, and lettuce on a cart. Further observation revealed flies around the plates landing on the food as the plates were uncovered as the dietary staff prepared three other…

    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 · F2023-08-07 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 39 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training and possessed the required certification in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 8/03/23 at 02:30 PM, Administrative Nurse D stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Administrative Nurse D stated she had not completed the training modules and had not taken the test for certification. The facility ' s Infection Preventionist policy, dated October 2022 documented the InfectionControl Preventionist is responsible for assessing, implementing, developing, monitoring the infection prevention and control program, coordinating and implementation with updating the established infection control policies 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-07 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 39 residents. Based on observation, interview, and record review the facility failed to ensure effective pest control in the facility kitchen. This deficient practice placed the residents of the facility at risk for decreased health and wellness. Findings included: - On 08/01/23 at 11:50 AM, observation during the noon meal service revealed a lot of flies in the kitchen landing on plates of residents' food and the food service utensils. Dietary Staff (DS) BB plated food slowly (first time doing this task) and the flies were getting on the food. On 08/01/23 at 12:00 PM, observation revealed, three plates with the noon meal of two soft tacos, Spanish rice, and lettuce on a cart with flies around the plates, landing on the food as the plates were uncovered while the dietary staff prepared three other plates of food. On 08/01/23 at 12:05 PM, Dietary BB stated she did not know where the flies had come from, but the kitchen had bug traps that were cleaned monthly by the exterminator. On 08/01/23 at 12:25 PM, Dietary CC stated the pest control company had just…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-07 · 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 39 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to notify the physician of Resident (R) 24's out of parameter blood pressures. This deficient practice placed R24 at risk for abnormally low blood pressures without physician awareness. Findings included: - R24's Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure) and congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R24 required supervision for eating, toileting, bed mobility, transfers, and total staff assistance with dressing. The MDS documented R24 received diuretic (help rid the body of salt (sodium) and water, commonly used to treat high blood pressure)…

    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 before2023-08-07 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 39 residents. The sample included 15 residents with one reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified a resident-to-resident altercation as an allegation of abuse and report to the facility abuse coordinator immediately for Resident (R)22. This placed the residents at risk for ongoing abuse and/or mistreatment. Findings included: - R22's Electronic Health Record (EHR) documented the resident had diagnoses of major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS further indicated the resident required extensive staff assistance with bed mobility,…

    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
Show the remaining 14 citations
  • Potential for harm · D2023-08-07 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 39 residents. The sample included 15 residents, with three reviewed for a Pre-admission Screening and Resident Review (PASARR- screening for individuals with mental disorder and individuals with intellectually disability). The facility failed to ensure a PASARR was completed for Resident (R)15 prior to admission to the facility. This placed the resident at risk for unidentified needs and inadequate care. Findings include: - R15 admitted to the facility on [DATE]. R15's Electronic Health Record (EHR), recorded the diagnoses of major depressive disorder (MDD-a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear,) and delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue). R15's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-07 · 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 39 residents. The sample included 15 residents with two residents reviewed for non-pressure skin issues. Based on observation, interview, and record review the facility failed to review or revise the care plan to include the physician ordered skin protective measures to prevent further skin damage for Resident (R) 34. This deficient practice placed R34 at risk for continued skin tears. Findings included: - R34's Electronic Medical Record documented diagnoses of left hand contracture (condition of shortening and hardening of muscles, anxiety disorder (group of mental conditions characterized by excessive fear), age-related osteoporosis (medical condition in which the bones become brittle and fragile), hemiplegia (muscle weakness on one side of the body), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and accidental puncture and laceration of skin tissue. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief…

    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 · D2023-08-07 · 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 had a census of 39 residents. The sample included 15 residents with two residents reviewed for non-pressure skin issues. Based on observation, interview, and record review the facility failed to provide physician ordered skin protective measures to prevent further skin damage for Resident (R) 34. This deficient practice placed R34 at risk for continued skin tears. Findings included: - R34's Electronic Medical Record documented diagnoses of left hand contracture (condition of shortening and hardening of muscles, anxiety disorder (group of mental conditions characterized by excessive fear), age-related osteoporosis (medical condition in which the bones become brittle and fragile), hemiplegia (muscle weakness on one side of the body), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and accidental puncture and laceration of skin tissue. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score 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 · Dcited before2023-08-07 · 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 39 residents. The sample included 15 residents with six reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure the environment remained free of accident hazards from unlocked chemicals and failed to povide a safe environment for Resident (R)17 who had a new electric lift recliner and fell from the recliner. This placed the affected residents at risk for injury due to preventable accidents and hazards Findings included: - On 08/01/23 at 08:20 AM, observation during initial facility tour revealed an unlocked shower room door on Country Hall. Further observation revealed the door contained a keypad to open the shower room door however was unlocked. The shower room contained the following: in an unlocked closet: 2-32 Ounce (oz) bottles of BNC-15 one step disinfectant with the warning keep out of reach of children, hazardous to humans and domestic animals, causes eye damage and skin burns. 4- 32 oz Bottles of Betco Ocean [NAME]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-07 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 39 residents. The sample included 15 residents, with three reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R)40, R7 and R24. This placed the affected residents at risk for injury. Findings included: - R40 's diagnoses included myocardial infarction (MI-heart attack), diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), fracture of radius (one of the bones going from the wrist to the elbow) and ulna (one of the bones going from the wrist to the elbow), morbid obesity (being 100 pounds or more above ideal body weight), and muscle weakness. R40's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS documented R40 required extensive assistance of two staff with bed mobility 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 · Dcited before2023-08-07 · 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 39 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility's consultant pharmacist failed to notify the physician or director of nursing that staff had not held (not administered) a blood pressure medication per the physician ordered parameters for Resident (R)24. This deficient practice placed R24 at risk for medication related issues. Findings included: - R24's Electronic Medical Record documented diagnoses of hypertension (high blood pressure) and congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R24 required supervision for eating, toileting, bed mobility, transfers, and total staff assistance with dressing. The MDS documented R24 received diuretic (help rid your…

    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 before2023-08-07 · 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 39 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to hold (not administer) a blood pressure medication per the physician ordered parameters for Resident (R)24. This deficient practice placed R24 at risk for abnormally low blood pressures. Findings included: - R24's Electronic Medical Record documented diagnoses of hypertension (high blood pressure) and congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R24 required supervision for eating, toileting, bed mobility, transfers, and total staff assistance with dressing. The MDS documented R24 received diuretic (help rid your body of salt (sodium) and water, commonly used to treat high blood pressure)…

    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 · Fcited before2022-01-19 · 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 37 residents. Based on observation, record review, and interview, the facility failed to provide a backflow device (unwanted flow of water in the reverse direction) or floor drain with a two inch air gap for the drainage system of the kitchen ice machine, and failed to store, prepare, and serve food under sanitary conditions for the 37 residents who received ice and food from the facility kitchen. This placed the affected residents at risk to receive contaminated ice and food. Findings Included: - On 01/18/22 at 01:30 PM, observation revealed one flex hose (flexible water supply tubes that connect plumbing fixtures and appliances to the plumbing system) from the back of the ice machine connected to plastic drainpipes. Continued observation revealed the drainpipes extended thru the dining room wall into the kitchen wall, then along the wall behind the dishwasher, approximately 12 feet into a floor drain. Further observation revealed the ends of the drainpipes were in the floor without a gap. On 01/18/22 at 01:35 PM, Maintenance Staff U verified the ice…

    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 · F2022-01-19 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a safe, sanitary, and comfortable environment for the residents who received their meals from the facility kitchen. This placed the 37 residents who resided in the facility and received their meals from the facility kitchen at risk for foodborne illness. Findings included: - On 01/13/22 at 08:30 AM, during initial tour, observation revealed the following: Six 12 inch x 12 inch square floor tiles chipped and pieces missing around the dishwasher area, with brownish debris/grime between the tiles and along the baseboard. Continued observation revealed the floor had chipped and missing linoleum throughout the kitchen . The baseboard and kitchen floor with brownish debris/grime between the tiles and along the baseboard. The facility's Sanitization policy, dated November 2017, documented the food service area shall be maintained in a clean and sanitary manner. Equipment should be cleaned, maintained, and in good repair, free from…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-19 · 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 37 residents. The sample included 12 residents with one reviewed for dialysis. Based on observation, record review, and interview, the facility failed to provide ongoing communication and assessment of the resident's dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment, including monitoring for Resident (R) 14. This placed the resident at risk for complications and health decline. Findings included: - R14's Physician's Order Sheet, dated 11/10/21 documented the resident had 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). R14's Quarterly Minimum Data Set (MDS), dated 11/19/21, recorded R14 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded he required extensive assistance of two staff for bed mobility, dressing, toileting, and personal hygiene. The MDS…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-19 · 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 37 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed follow up on the facility's consultant pharmacist recommendatons for a 14 day stop date on as needed (PRN) Haldol (antipsychotic medication used to treat severe behaviors) for Resident (R) 6, and laboratory tests to monitor blood iron levels for R18. This placed R6 and R18 at risk for adverse medication side effects. Findings included: - The Physician Order Sheet, dated 01/06/22, recorded R6 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), major depression (mental health disorder characterized by persistent depressed mood, causing significant impairment of daily life), delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue) and anxiety (mental health disorder characterized by worry and fear that…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-19 · 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 37 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview the facility failed to complete pharmacist recommended laboratory tests to adequately monitor blood iron levels (ability of blood cells to carry oxygen) for one of five sampled residents, Resident (R) 18. This placed R18 at risk for ineffective medication results and adverse side effects. Findings included: - The Physician Order Sheet, dated 12/03/21, recorded diagnoses of Parkinson's Disease (slowly progressive neurologic disorder characterized by tremors, muscle rigidity, and weakness), iron deficiency anemia (low iron levels in blood cause lack of oxygen to internal organs), and protein-calorie malnutrition (lack of iron and other nutrients in blood cells). The Annual Minimum Data Set (MDS), dated [DATE], recorded R18 had a Brief Interview for Mental Status score of 11 (moderate cognitive impairment), and required extensive staff…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-19 · 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 37 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a 14 day stop date or physician's rationale for extended use for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for one sampled resident, Residents (R) 6. This placed R6 at risk to receive unnecessary psychotropic medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 01/06/22, recorded R6 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), major depression (mental health disorder characterized by persistent depressed mood, causing significant impairment of daily life), delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue) and anxiety (mental health disorder characterized by worry and fear that interferes…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-08-07 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 39 residents. The sample included 15 residents. Based on record review and interview the facility failed to deliver mail to the facility residents on Saturdays. Findings included: - On 08/01/23 at 01:46 PM during the resident council meeting, the residents verbalized there was no mail delivery on Saturdays. On 08/07/23 at 01:30 PM, Administrative Staff A verified the mail was delivered directly to the facility's mailbox located outside of the facility, beside the entrance driveway, from the Post Office Monday through Saturday. Administrative Staff A verified Monday through Friday, the Activity Director or Social Services Designee would deliver the mail to residents; on Saturday, the charge nurse would deliver the mail to the residents but was unsure if the nurse would deliver it to the residents. On 08/07/23 at 11:30 AM interview with Licensed Nurse (LN) H verified she did work weekends and had not gotten the mail from the mailbox since she had been employed at the facility. On 08/07/23 at 11:40 AM, interview with Certified Nurse Aide (CNA) O verified…

    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

“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.

Part of a chain

This home belongs to MISSION HEALTH COMMUNITIES — 30 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.8+0.2 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 3 of 52.9+0.1 vs chain
Quality measures 4 of 52.9+1.1 vs chain
The other 29 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Colby Operator, LLCColby, KS 1 of 5Dickson Health And RehabDickson, TN 1 of 5Hutchinson Operator, LLCHutchinson, KS 1 of 5Kaw River Care And RehabEdwardsville, KS 1 of 5Lincoln Care And RehabWichita, KS 1 of 5North Ridge Health And RehabNew Hope, MN 1 of 5Providence Living CenterTopeka, KS 2 of 5Columbus Health and RehabColumbus, WI 2 of 5Edwardsville Care And RehabEdwardsville, KS 2 of 5El Dorado Care And RehabEl Dorado, KS 2 of 5Spring Hill Care And RehabSpring Hill, KS 3 of 5Chase County Care And RehabCottonwood Falls, KS 3 of 5Eskridge Care And RehabEskridge, KS 3 of 5Lansing Care And RehabLansing, KS 3 of 5Neodesha Care And RehabNeodesha, KS 3 of 5Parkway Operator LLCEdwardsville, KS 3 of 5Pittsburg Care And RehabPittsburg, KS 3 of 5Rolling Hills Health And RehabWichita, KS 3 of 5Wilson Care And RehabWilson, KS 4 of 5Arma Operator, LLCArma, KS 4 of 5Onaga Operator, LLCOnaga, KS 4 of 5Oswego Operator, LLCOswego, KS 4 of 5Peabody Health And RehabPeabody, KS 4 of 5Pratt Health And RehabPratt, KS 4 of 5Smith Center Health And RehabSmith Center, KS 4 of 5Wakefield Care And RehabWakefield, KS 5 of 5Botkin Care And RehabWellington, KS 5 of 5Downs Care And RehabDowns, KS 5 of 5Wellington Health And RehabWellington, KS

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
KANSAS OPERATOR LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/25/2015
BARRES, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
T AND C CAPITAL ASSETS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
WINDWARD HEALTH PARTNERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
CRINO, BRYANIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
FEUER, SCOTTIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
LINDEMAN, STUARTIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 02/26/2015
PASSERO, JOSEPHIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
YOAKUM, JAMIEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/19/2024
MISSION HEALTH COMMUNITIES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/26/2015

CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$4.8M
Net patient revenuemost recent cost report
+6.0%
Operating marginrevenue minus expenses
$296K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 80%Medicare 14%Other / private 6%

About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $296K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$313per resident / day
operating cost
$9,517per month
≈ monthly operating cost
$333per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175437. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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