Bethel Home
300 S Aztec St, Montezuma, KS 67867 · Non profit - Church related · 56 certified beds · (620) 846-2241 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.4% | 17.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.3% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.3% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.2% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.0% | 16.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.7% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.5% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 22.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.5% | 18.1% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.19 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.25 | 2.13 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
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.
Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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
How full it usually is: this home is certified for 56 beds and averages 53.9 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 4.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.549 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.35 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 4.00 hrs/resident/day on weekends vs 4.82 on weekdays — 17% thinner on weekends. RN hours go from 0.65 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first — scroll within the box to see all.
- Actual harm · Gcited before2023-02-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 54, with 4 sampled for pressure injuries. Based on observation, interview, and record review the facility failed to establish and maintain a system to identify, track, and measure wounds when Residents (R) 51 admitted to the facility with two pressure injuries (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) and had multiple wounds develop with no measurements, description, or follow up documented in the resident's record. The facility further failed to identify, document, and track a deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister) on R54's heel, which included measurements, description, and/or follow up regarding the wound. As a result of the deep tissue injury the resident reported she experienced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-16 · tag F0657 — failed to keep the care plan current — patternDevelop 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
The facility had a census of 50 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise the fall care plan with an appropriate intervention for two residents. Resident (R) R33 and R36. Additionally, the facility failed to update care plan with facility acquired pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for R2, and R23's care plan was not updated with psychotropic (alters mood or thought) medications changes. These deficient practices had the potential to have a negative effect on the overall physical and psychosocial well-being of the residents in the facility. Findings included: - During the onsite survey, the surveyors identified a concern regarding the revision of care plans for four of the sampled residents. R36's Electronic Health Record (EHR) revealed the care plan lacked fall intervention. The fall that occurred on 12/12/24 had no intervention placed to prevent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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
The facility had a census of 50 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for four residents. Resident (R) 37 who had medications located in her room that was not secured. Additionally, three residents R21, R33, and R36 had repeated falls with inappropriate or lacked a care plan revision after falls. These failures placed the affected residents at risk for preventable accidents and related injuries. Findings included: - During the onsite survey, the surveyors identified a concern regarding the unsecured medications observed in one resident's room during interview. Additionally, three residents noted to have repeated falls, when care plans were reviewed, falls that had occurred either lacked an intervention, or an appropriate intervention was completed. During an observation on 01/14/25 at 01:36 PM, R37 had three over the counter medications on her over the bed table. A jar of Amish Origins Deep Penetrating Pain Relief Cream (used for arthritis, sore…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 50 residents. The sample included 14 residents reviewed for person-centered care plan development. Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for three residents, Resident (R) 33 related to psychotropic (any class of medications that alter mood or thought) medication use and dementia (a progressive mental disorder characterized by failing memory, confusion) care. R21's care plan lacked interventions related to as needed (PRN) oxygen use and scheduled nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication use. Additionally, R21's care plan lacked a timely intervention related to the care of pressure ulcer/injury (areas of 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). R3's care plan lacked interventions related to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 50 residents with 14 residents sampled, which included one resident 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 observations, interviews, and record review, the facility failed to perform an ongoing assessment of a stage three (full thickness pressure injury extending through the skin into the tissue below) facility acquired pressure ulcer for Resident (R) 2. Findings included: - R2's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord). The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 reported a census of 50 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure Resident (R)46's as needed (PRN) psychotropic (any class of medications that alters mood or thought) medication had the required 14 day stop date or clinical rationale for continued use beyond the initial 14 days. This deficient practice had the potential to lead to the resident receiving unnecessary psychotropic medications. Findings Included: - R46's Electronic Health Record (EHR) revealed diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and hypertension (elevated blood pressure). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident received antianxiety (a class of medications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 50 residents. Based on observations, interviews, and record review, staff failed to complete proper hand hygiend during wound care for Resident (R)2 and R21, to ensure best practice regarding infection control and prevention. Findings included: - Observation on 01/15/25 at 07:00 AM, Licensed Nurse (LN) J removed a dressing from a skin tear on R21's without hand hygiene, cleaned the wound with normal saline (NS- saline water solution for medical use) and gauze, did not change her gloves or perform hand hygiene, placed new border foam dressing, then transitioned to morning Activities of Daily Living (ADL) assistance with glove change only, no hand hygiene. Observation on 01/15/25 at 07:03 AM, R2 was assisted back into bed by Certified Nursing Assistant (CNA) O and CNA N. CNA O assisted R2 with dressing then removed gloves, put on new gloves but did not wash her hands, then applied Foley tubing to R2's leg. Observation on 01/15/25 at 07:19 AM, LN H and CNA N entered a resident's room and applied PPE with no concerns. LN H cleansed wound to right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 50 residents. Based on interview and record review the facility failed to ensure an effective and ongoing antibiotic stewardship for appropriate antibiotic use for the residents of the facility to prevent antibiotic resistance and the spread of multi-drug resistant organisms Findings included: - During an interview on 01/16/24 at 08:15 AM, Administrative Nurse C reported she is the Infection Preventionist (IP- a trained healthcare professional who works to prevent the spread of infections in healthcare facilities) for the facility. Administrative Nurse C revealed she tracked when an antibiotic started, she reported the nurses on the units were to follow McGeer's Criteria (a set of guidelines for identifying infections in long-term care facilities) and notify her when a new antibiotic was started. Administrative Nurse C reported this did not happen. Administrative Nurse C reported she was not notified that R30 was being tested for clostridium difficile (C-diff: contagious bacteria characterized by foul smelling frequent loose bowel movements) on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 reported a census of 55 residents with one resident reviewed for accident hazards. Based on interview, observation, and record review, the facility failed to ensure a safe environment for one resident with the failure to remove the keys from a facility owned vehicle/golf cart, which allowed Resident (R1) to leave the facility in the golf cart, without the knowledge of staff, and operate the vehicle on public roadways. Findings include: - Review of R1's Electronic Health Record (EHR) documented R1 had the diagnoses that included weakness, unspecified pain and dorsalgia (a chronic [lasting more than three months] symptom of generalized back pain which may be a result of many different conditions). The 05/18/23 Quarterly Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The resident had no exit seeking behaviors. The resident required assistance of one staff for walking in his room, but was able to walk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-02-01 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure 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
The facility reported a census of 54 residents. Based on observations, interviews, and record review the facility failed to ensure the competency of Licensed Nurses in the facility regarding wound/skin issues of residents to include the monitoring, measuring, identifying of skin issues and pressure injuries (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). This deficient practice placed any resident with potential skin issues, at risk of worsening and further development of skin related injuries. (See F610, F655, F684, F686) Findings included: - Upon day one of survey in the facility on 01/30/23, the facility provided a Matrix form, which identified only Resident (R)51 with a stage I pressure ulcer. Upon interview with Administrative Nurse D on 02/01/23 the facility provided another Matrix form (dated 02/01/23 at 09:40 AM), which identified R41with a stage II pressure ulcer and R51 with a stage I pressure ulcer. Investigation revealed the lack of ensuring Licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-02-01 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 54 residents. Based on observation, interview, and record review the facility failed to ensure the QAPI committee developed and implemented timely action plans to address the quality deficiencies as identified in the annual health resurvey. This failure placed all resident with actual and/or potential skin integrity issues at risk. Findings included: - During the annual health resurvey conducted on 01/30-02/01/23 the following concerns were identified: 1. The facility failed to initiate an investigation, when Resident (R) 51 sustained bruising to his left wrist, right forearm, and a skin tear to the back of his right hand with no documentation or follow to determine the origin of the resident's injuries. The facility further failed to place interventions/protections, to ensure the resident did not sustain further injuries. (See F610) 2. The facility failed to develop and implement a baseline care plan for Resident (R) 54, which included instructions needed to provide effective and person-centered care of the resident and met professional standards…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-01 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 census totaled 54, with one resident sampled for an injury of unknown origin. Based on observation, interview, and record review the facility failed to initiate an investigation, when Resident (R) 51 sustained bruising to his left wrist, right forearm, and a skin tear to the back of his right hand with no documentation or follow to determine the origin of the resident's injuries. The facility further failed to place interventions/protections, to ensure the resident did not sustain further injuries. Findings included: - Review of the R51's Electronic Health Record revealed the resident had diagnoses of fracture of the right femur (thigh bone) and Parkinson's Disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of two, which indicated severely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-01 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 54, with 4 sampled for pressure injuries. Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for Resident (R) 54, which included instructions needed to provide effective and person-centered care of the resident and met professional standards of quality care, when the resident developed a deep tissue injury to the left heel with no documentation or interventions in place on the resident's baseline care plan. Findings included: - Review of R54's Electronic Health Record revealed the resident had a diagnosis of fracture of the right lower leg. Review of the 01/17/23 admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The resident required formal and clinical assessments for pressure injury risk. The resident had a risk of pressure injury development and had one or more unhealed pressure injuries. The resident had 1 unstageable…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 census totaled 54, with one resident sampled for non-pressure related skin conditions. Based on observation, interview, and record review the facility failed to identify, document, track, and measure skin issues when Resident (R) 23 had multiple skin tears, bruising and surgical removal of a cancerous lesion on the ear and had no measurements, description or follow up documented in the R23's record. Findings included: - Review of R23's Electronic Health Record revealed the resident had a diagnosis of unilateral primary osteoarthritis (inflammation of one or more joints), dysthymic disorder (chronic form of depression), and erythema intertrego (inflamed areas from skin-to-skin contact). Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R23 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The resident required limited assistance of one staff for bed mobility, transfer, toilet use, personal hygiene, and dressing. Review of the 03/17/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-03-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 reported a census of 52 residents, with 11 included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of insulin (a hormone produced in the pancreas) when staff failed to report out of parameter blood glucose (main sugar that the body makes from the food in the diet) levels for Resident (R) 45, per physician's orders. Findings included: - Review of R45's signed Physician Order Sheet (POS) dated 03/02/21 documented the following diagnoses: Diabetes Mellitus (DM, when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and dementia (progressive mental disorder characterized by failing memory, confusion). Review of R45's Annual Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) of 03, indicating severely impaired cognition. The MDS noted R45 had DM and she received daily insulin injections. Review of R45's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ISAAC, TRAVIS | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| JOHNSON, LANCE | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| KOEHN, DON | Individual | CORPORATE DIRECTOR | since 01/01/2021 |
| KOEHN, LENNIS | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| KOEHN, PRESLEY | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| NICKEL, BRENTON | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| SCHOWENGERDT, ANDREW | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/1991 |
| UNRUH, BRANDON | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| UNRUH, DAVID | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| YOST, CHRIS | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| ENSZ, TERRY | Individual | CORPORATE OFFICER | since 01/01/2021 |
| KOEHN, EUGENE | Individual | CORPORATE OFFICER | since 01/01/2018 |
| SMITH, JAMES | Individual | CORPORATE OFFICER | since 01/01/2021 |
| KOEHN, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/13/2018 |
CMS files one row per role, so the 17 rows in the source record cover these 14 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.
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 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
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
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.
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 175528. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-16, 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.