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The Cedars

1021 Cedars Drive, McPherson, KS 67460 · Non profit - Corporation · 54 certified beds · (620) 241-0919 Medicare & Medicaid certified

Call the home — (620) 241-0919 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2022Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • 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 an abuse, neglect, or exploitation citation (F0600), cited Aug 2022
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — 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 (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

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 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 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
218 N Ash St · (800) 803-2523 · Call to confirm hours
Grocery
820 E Kansas Ave · (620) 241-3403 · Call to confirm hours
Park
1108 E Simpson 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 3 of 5
Long-stay residentspeople who live here 1 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 increased27.8%17.9%15.4%worse
Long-stay residents who lose too much weight5.1%4.9%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection1.8%2.9%2.0%typical
Long-stay residents with depressive symptoms3.6%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.8%4.3%3.3%worse
Long-stay residents whose ability to walk worsened31.4%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.9%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine89.3%95.5%95.3%typical
Long-stay residents with pressure ulcers6.3%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control23.1%22.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table18.8%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.7%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine62.5%73.8%79.4%worse
Short-stay residents rehospitalized after admission24.9%22.4%22.6%worse
Short-stay residents with an outpatient ER visit7.0%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.371.801.67better
Long-stay outpatient ER visits per 1,000 resident days2.792.131.80worse

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.

64.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.8%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
64.4%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 64.4% 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 45 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 SNF64.8%CMS range 54.2–72.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.4–14.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge64.4%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 discharge55.6%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 discharge31.1%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 identified79.6%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.9%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 hospitalization6.2%CMS range 3.0–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.731.02Oct 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

0.73
RN hours/ resident / day
1.12
LPN hours/ resident / day
3.13
Aide hours/ resident / day
4.98
Total nurse hours/ resident / day
0.23
RN hoursweekends
64.4%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 54 beds and averages 38.6 residents a day — about 71% occupied, or roughly 15 beds typically open. It usually has some room. 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 4.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.13 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.52 hrs/resident/day on weekends vs 5.17 on weekdays — 13% thinner on weekends. RN hours go from 0.93 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above 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

9
deficiencies at the latest standard inspection (2026-01-22)
12
at the previous standard inspection (2024-03-11)

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Dcited before2026-01-22 · 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

    The facility had a census of 33. The sample included 12 residents. Based on record review, interview, and observation, the facility failed to provide care for Resident (R) 23 who had a Brief Interview for Mental Status (BIMS) score of eleven, which indicated moderately impaired cognition in a manner that protected and promoted their dignity.Findings included: - On 01/21/26 at 07:55 AM, observation revealed R23 sat at the dining room table. Licensed Nurse (LN) G obtained R23's blood sugar reading using a glucometer (an instrument used to calculate blood glucose) from R23's right index finger. LN G stated, Your blood sugar reading is high. We probably need to contact your doctor and see if he wants to start you on insulin. Continued observation revealed five residents seated in the dining room awaiting breakfast to be served, while other staff and a visitor were in the dining room as well.On 01/22/26 at 10:00 AM, Administrative Nurse D stated staff should not check a resident's blood sugar reading in the dining room. Administrative Nurse D stated staff should take the resident to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-22 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility has a census of 33 residents. The sample included 12 residents, with three reviewed for Beneficiary Notices. Based on interview and record review, the facility failed to provide two sampled residents, Resident R9 and R28 (or their representative), with the completed Notice of Medicare Non-Coverage (NOMNC) Form 10123, Centers for Medicare and Medicaid Services (CMS).Findings include:- The facility lacked the documentation staff provided R9, or his representative, form 10123, which included a detailed explanation of non-coverage and explained the appeal process. The resident's skilled services ended on 11/20/25.The facility lacked the documentation staff provided R28, or his representative, form 10123, which included a detailed explanation of non-coverage and explained the appeal process. The resident's skilled services ended on 01/13/26.On 01/23/26 at 01:40 PM, Administrative Staff A verified that Form 10123 was not provided to the two residents and should have been given to the resident or the representative.The Medicare form 10123 informed the beneficiary that Medicare…

    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 · D2026-01-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R) 11's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. The facility further failed to ensure R5 and R31's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date.Findings Included: - R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson's disease (a slowly progressive…

    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 · D2026-01-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 12 residents, with one reviewed for discharge. Based on the interview and record review, the facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of Resident (R) 49's stay.Findings included:- The Electronic Medical Record (EMR) for R49 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), acute blood loss anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to the body tissues), and lower gastrointestinal bleed (bleeding into the stomach and/or digestive tract).The admission 5-Day Medicare Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R49 required partial staff assistance with toileting hygiene, showers, dressing, personal hygiene, and transfers.R49's Care Plan dated 10/14/25 documented…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-22 · 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 had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to implement interventions for diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or he body cannot respond to the insulin) management for one resident, Resident (R) 2, and failed to implement individualized fall interventions for one resident, R31.Findings included:- The Electronic Medical Record (EMR) for R2 documented a diagnosis of diabetes mellitus.The admission Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status score (BIMS) of 13, which indicated intact cognition. R2 was dependent upon staff for toileting hygiene, mobility, transfers, and did not ambulate. The MDS further documented that R2 received insulin (controls blood sugar by moving glucose from the blood into the cells) daily.R2's Care Plan dated 01/09/26 directed staff to provide R2 a protein snack during 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 before2026-01-22 · 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 resident census of 33. The sample included 12 residents, of whom seven were reviewed for accidents. Based on observation, interview, and record review, the facility failed to follow the plan of care for one resident, Resident (R) 9, who had falls in his room and a fall with injury because his shoes were too big. The facility failed to provide a safe environment for R43, who had two falls involving the sit-to-stand lift (which helps transfer residents from one seated surface to another) and did not follow the plan of care.Findings included:- The Electronic Medical Record (EMR) documented R9 had diagnoses of Dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion) and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented R9 had a Brief Interview 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · 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 33 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to obtain blood sugar parameters from the physician for one resident, Resident (R) 2, who had her blood sugar taken four times per day.Findings included:- The Electronic Medical Record (EMR) for R2 documented diagnosis of diabetes mellitus (DM -when the boy cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The admission 5-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R2 is dependent upon staff for toileting hygiene, mobility, transfers, and does not ambulate. The MDS further documented that R2 received insulin (controls blood sugar by moving glucose from the blood into the cells) daily.R2's Care Plan dated 01/09/26 directed staff to provide R2 a protein snack during…

    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 · D2026-01-22 · 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 33 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 attends 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) 23.Findings included:- R23's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), metabolic encephalopathy (when the brain has trouble functioning because of a chemical, or metabolic problem in the body), diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), atrial fibrillation (rapid, irregular heartbeat), and chronic pain.R23's Significant Change Minimum Data Set (MDS) dated [DATE]…

    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 · D2024-11-12 · 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

    The facility had a census of 31 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure staff identified an allegation of rough care as potential abuse and reported immediately to the Licensed Nursing Home Administrator (LNHA). The facility further failed to report the allegation of abuse to the State Agency (SA) as required. This placed the resident at risk for ongoing abuse and mistreatment. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), personal history of malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the breast, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data…

    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 · D2024-11-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 31 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to initiate protective measures and fully investigate an allegation of abuse for Resident (R) 1. This placed the resident at risk for ongoing abuse. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), personal history of malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the breast, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set dated 09/01/24, documented R1 had severe cognitive impairment. R1 had verbal behaviors directed toward others and rejected care for one to three days 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · F2024-03-11 · 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. The facility had one main kitchen and three kitchenettes. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 37 residents who received their meals from the facility's kitchens when staff stored unlabeled, undated food in the refrigerators. Staff did not sanitize the thermometer between food items when checking food temperatures and failed to ensure clean and sanitary preparation areas. This placed the 37 residents at risk for foodborne illness. Findings included: - On 03/05/24 at 08:05 AM, observation in the kitchen revealed the following: An updated, unlabeled plastic bag with liquid coffee. 12 uncovered, undated, and unlabeled slices of cheese. An undated, unlabeled plastic container of barbeque sauce. On 03/05/24 at 08:05 AM, Dietary Staff (DS) BB verified the above finding and stated food items placed in the refrigerator should be labeled, dated, and completely covered. DS BB disposed of the food…

    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 · F2024-03-11 · 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 had a census of 37 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 2 indicated the facility did not have a Registered Nurse (RN) on 5 dates, FY 2023 Quarter 3 indicated no RN for on 91 dates and FY 2023 Quarter 4 for 26 dates. The PBJ also indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days in FY 2023: Quarter 3 for 91 dates and Quarter 4 for 31 dates. The PBJ further indicated Fiscal YR 2024 Quarter 1 did not have an RN for 26 days and did not have a licensed nurse coverage 24 hours a day, seven days a week for 46 dates. A review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed an RN for eight…

    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 · Dcited before2024-03-11 · 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

    The facility had a census of 37 residents. The sample included 15 residents with one reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) 29 with dignity when staff checked his blood glucose level at the dining room table with two other residents able to view the procedure. This placed the resident at risk for an undignified experience. Findings included: - On 03/05/24 at 10:57 AM, observation revealed in the 300-House dining room, Certified Medication Aide (CMA) R used a glucometer (an instrument used to calculate blood glucose) to check R29's blood glucose level at the dining room table during the meal service and dining. There were two other residents present and able to view the procedure. On 03/11/24 at 10:46 AM, Administrative Nurse D stated she expected staff to take R29 to his room or a private area when they checked his blood glucose level. The facility's Supporting the Resident's Right to Privacy and Confidentiality Policy, revised 02/2009, documented it was the responsibility of each employee 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-11 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 15 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) for skilled services for Resident (R) 16, R17, and R190 which included the estimated cost of services. This placed the resident at risk for uninformed care decisions. Findings included: - The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay for skilled services and provided a cost estimate of continued services. The form included an option for the beneficiary to (1) receive the specified skilled services listed, and bill Medicare for an official decision on payment. The recipient understands if Medicare does not pay, the recipient is responsible for payment but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, the recipient is responsible for payment for services. (3) the recipient does not want the listed therapy services. 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-11 · 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 37 residents. The sample included 15 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent avoidable accidents. This placed the resident at risk for further accidents due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, macular degeneration (progressive deterioration of the retina), epilepsy (brain disorder characterized by repeated seizures), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), falls, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had severely impaired cognition. R7 was dependent on staff for toileting and required substantial/maximum assistance for dressing and bathing. R7 required…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-11 · 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 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to assess and treat Resident (R) 32's alteration in bowel movements, which placed the resident at risk of ongoing constipation and possible fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move) complications. Findings included: - R32's Electronic Medical Record (EMR) included diagnoses of acute respiratory failure with hypoxia or hypoxia (inadequate supply of oxygen), dementia (a progressive mental disorder characterized by failing memory, and confusion), and constipation. The admission Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition, disorganized thinking which fluctuated, and other behavioral symptoms not directed to others which occurred daily that significantly disrupted care or living environment. R32 required set-up and clean-up assistance with eating and partial to moderate…

    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 · D2024-03-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 37 residents. The sample included 15 residents, with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement nutritional interventions to promote healing for one resident, Resident (R) 11, after development of a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer. This placed the resident at risk for complications from pressure injuries and delayed healing. Findings included: - The Electronic Medical Record (EMR for R11 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath),…

    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 before2024-03-11 · 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 37 residents. The sample included 15 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from preventable accident hazards for Resident (R) 7, who spilled her hot tea onto her lap twice in one week. This placed the resident at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, macular degeneration (progressive deterioration of the retina), epilepsy (brain disorder characterized by repeated seizures), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), falls, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had severely impaired cognition. R7 was dependent on staff for toileting and required substantial/maximum assistance for dressing and bathing.…

    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 · D2024-03-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 15 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 32 with sanitary indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care and treatment which placed the resident at risk for urinary tract infections (UTI). Findings included: - R32's Electronic Medical Record (EMR) included diagnoses of acute respiratory failure with hypoxia or hypoxia (inadequate supply of oxygen), dementia (a progressive mental disorder characterized by failing memory, and confusion), constipation (difficulty passing stools), retention of urine, delirium (sudden severe confusion, disorientation and restlessness), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid, pain, and encephalopathy (broad term for any brain disease that alters brain function or structure). The admission Minimum Data Set (MDS), dated [DATE], documented R32 had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 15 residents. Based on observation, record review, and interview, the facility failed to provide appropriate respiratory care and services when staff failed to store oxygen cannula and tubing in a sanitary manner for Resident (R) 14. This placed the resident at risk for respiratory infections. Findings included: - R14's Electronic Medical Record (EMR) documented R14 had diagnoses of pneumonia (inflammation of the lungs), Crohn's disease (chronic inflammatory bowel disease), acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), and hypercapnia (high levels of carbon dioxide in the blood), and major depressant disorder (major mood disorder which causes persistent feelings of sadness). R14's Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition. R14 required partial to moderate assistance with toileting hygiene, upper and lower body dressing, rolling side to side, sitting from lying, 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 · D2024-03-11 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 15 residents. Based on observation, record review, and interview the facility failed to prepare a nourishing well well-balanced pureed diet that followed the menu and included a vegetable for Resident (R)190, who requested vegetables. This placed the resident at risk for dissatisfaction and impaired nutrition. Findings included: - On 03/06/24 at 09:50 AM, observation in the main kitchen revealed Dietary Staff (DS) BB stated the facility had one resident (R190) who received a pureed diet. Observation revealed DS BB placed five half-ounce (oz) meatballs with sauce into a blender and blended to the consistency of pudding. DS BB used a spatula to transfer the pureed meatballs to a metal pan and placed the pan in the warmer. When asked how R190 would receive her vegetables, DS BB stated R190 had not requested any. On 03/06/24 at 10:41 AM, observation of R190's noon meal dietary order sheet revealed that R190 had soft-cooked vegetables circled. DS CC verified R190 had circled soft, cooked vegetables and stated it meant she had…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure adequate infection control measures when staff did not practice appropriate hand hygiene when providing incontinence care for Resident (R) 12, or for R4 during medication administration. This placed the residents at risk for infection. Findings included: - The Electronic Medical Record (EMR) for R12 documented diagnoses of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), atrial fibrillation (rapid, irregular heartbeat), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had moderately impaired cognition and was dependent upon staff for toileting, substantial/maximum assistance for dressing, personal hygiene, and transfers. The MDS documented R12 was continent of bowel. The Care…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 51 residents. The sample included 13 residents with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to prevent an incident of abuse and/or retaliation for Resident (R)23, when agency Licensed Nurse (LN) G refused to give R23 his evening medications then took the residents cell phone out of his hand, threw it in the recliner, refused to let the resident to call the police and then transferred R23 using a lift whereas R23 sustained a skin tear during the transfer. This deficient practice placed R23 at risk for physical injury and impaired psychosocial wellbeing. Findings included: - R23's Physician Order sheet, dated 08/16/22 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dry eye syndrome,…

    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 · D2022-08-29 · tag F0675 — failed to support quality of life — isolated
    Honor each resident's preferences, choices, values and beliefs.
    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 51 residents. The sample included 13 residents with one reviewed for quality of life. Based on observation, record review, and interview, the facility failed to ensure all staff honored and responded to Resident (R)23's preferences, requests and choices to ensure R23's quality of life. This deficient practice placed R23 at risk for decreased psychosocial wellbeing and impaired dignity and autonomy. Findings Included: - R23's Physician Order sheet, dated 08/16/22 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dry eye syndrome, facial dermatitis (a condition of the skin in which the skin becomes red swollen, and sore, sometimes with small blisters, resulting from direct irritation of the skin by an external agent or allergic reaction to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-29 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 51 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to ensure staff possessed the appropriate skills and competencies when staff failed to complete post-fall neurological assessments for one of three residents reviewed for accidents, Resident (R) 9. This placed R9 at increased risk for unrecognized fall related injury and delayed treatment. Findings included: -The Medical Diagnosis section within R9's Electronic Medical Record (EMR) included diagnoses of transient cerebral ischemic attack (TIA-episode of cerebrovascular insufficiency), epilepsy (brain disorder characterized by repeated seizures), dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, fall trip with strike against object and depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly Minimum Data Set…

    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 · D2022-08-29 · 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 51 residents. The sample included 13 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to follow up on the consultant pharmacist recommendations to ensure the facility obtained a risk versus benefit statement annually for the continued use of Seroquel (antipsychotic drug) for R42 and an appropriate diagnosis for the use of Seroquel for R16. This deficient practice placed R16 and R42 at risk for unnecessary drugs. Findings included: - R42's Physician Order Sheet (POS), dated 08/04/22, documented diagnoses of anxiety disorder (disorder characterized by feelings of worry, anxiety) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. R42 required supervision for eating and one…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-29 · 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 51 residents. The sample included 13 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure two sampled Residents (R) did not receive unnecessary psychotropic medications (class of medications which alter mood or thought) when they failed to obtain a risk versus benefit statement for the continued use of Seroquel (antipsychotic drug) for R42 and an appropriate diagnosis for the continued use of Seroquel for R16. This deficient practice placed R16 and R42 at risk to receive unnecessary psychotropic drugs. Findings included: - R42's Physician Order Sheet (POS), dated 08/04/22, documented diagnoses of anxiety disorder (disorder characterized by feelings of worry, anxiety) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS)…

    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 · D2022-08-29 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 51 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to ensure one of seven residents reviewed during medication administration pass remained free of medication errors. This deficient practice placed Resident (R) 23 at risk for adverse reaction from the medication. Findings included: - R23's Physician Order sheet, dated 08/16/22 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dry eye syndrome, facial dermatitis (a condition of the skin in which the skin becomes red swollen, and sore, sometimes with small blisters, resulting from direct irritation of the skin by an external agent or allergic reaction to it,) chronic kidney disease Stage 4 (kidneys are severely damaged and are not working to clear filter waste from your blood) and chronic pain.…

    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 · C2026-01-22 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 33 residents who resided in the facility and received their meals from the kitchen. Findings included:- On 01/20/26 at 09:00 AM, observation revealed that dietary staff in the kitchen prepared the lunch meal. On 01/20/26 at 09:30 AM, Dietary Staff BB verified she was not a certified dietary manager, stated she was taking the course to become certified, and would need to take the test to become certified. Dietary Staff BB stated the facility had two residents with a pureed (smooth, moist, pudding-like food that requires no chewing, designed for residents with severe swallowing or chewing difficulties) diet and three with a minced and moist (soft, moist foods that are easy to swallow and require minimal chewing) diet. On 01/22/26 at 01:00 PM, Administrative Staff A verified Dietary Staff BB was not certified.The facility's Personnel policy, dated 03/26/24, documented…

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

    Nutrition and Dietary 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
BRYANT, STEPHANIEIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 04/07/2017
NEUFELDT, APRILIndividualCORPORATE DIRECTORsince 08/01/2018

CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$9.0M
Net patient revenuemost recent cost report
-26.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 48%Medicare 5%Other / private 47%

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

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

Cost & finances

$925per resident / day
operating cost
$28,105per month
≈ monthly operating cost
$732per day
avg. revenue, all payers

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

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175380. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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