Moran Manor
3940 Us Hwy 54, Moran, KS 66755 · For profit - Corporation · 45 certified beds · (620) 237-4300 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,069 in federal fines (most recent 2025-03-20)
- its facility-reported quality-measure rating is low (2/5)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 fell from 3 to 2 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 | 14.4% | 17.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.9% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.5% | 6.5% | 6.5% | better |
| 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 | 4.4% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.9% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.4% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 87.9% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.2% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 31.8% | 18.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.4% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 61.9% | 73.8% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.13 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 4.90 | 2.13 | 1.80 | worse |
‡ 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.
51.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.0% 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 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 51.9%CMS range 35.1–65.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.1–15.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 55.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 55.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 93.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.0%CMS range 3.1–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 45 beds and averages 36.2 residents a day — about 80% occupied, or roughly 9 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.446 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.20 hrs/resident/day on weekends vs 3.80 on weekdays — 16% thinner on weekends. RN hours go from 0.99 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-03-20 · 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 34 residents, with one resident sampled for accidents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free of accident hazards during transportation. On 01/21/25, Transportation Staff E and Certified Nurse Aide (CNA) D did not ensure R1 was safely secured in the transportation vehicle before operating the vehicle. CNA D, who secured R1 in the transportation vehicle, lacked appropriate training and competency evaluation. Transportation Staff D failed to ensure R1's wheelchair was appropriately secured then operated the vehicle in a manner that caused the CNA to fear for her safety and the safety of the resident, by frequently looking at his phone which caused the vehicle to cross the [NAME] strips (corrugated pavement along the side of the road that causes rumbling and vibration when driven over to alert inattentive drivers of potential danger) on the right and left (center and shoulder) sides of the road multiple times…
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 · Fcited before2025-06-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 36 residents with one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage to prevent the spread of food borne illness to the residents of the facility. This placed the residents at risk for food-borne illness. Findings included: - Initial tour of the kitchen on 06/02/35 at 02:51 PM with Dietary Manager BB, revealed the following areas of concern: The stand-up freezer in the kitchen area contained BBQ ribs open to air and undated. There were frozen vegetables in a bag, opened and not dated. The stand-up refrigerator in the kitchen contained salad opened to air and not dated. It also contained cottage cheese, sour cream, and cream opened but not dated. The dry storage area had a freezer with frozen peas that was open to air. The kitchen area had a cutting board with deep grooves and scratches on it. During an interview on 06/02/25 at 03:05 PM, Dietary Manager BB reported she expected all food to be dated and covered. Dietary Manager BB further stated all equipment should have…
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 · F2025-06-04 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 36 residents. The sample included 14 residents. Based on interviews, record reviews and observation, the facility failed to maintain an effective pest control program to ensure the kitchen was free from insects and/or pests. This deficient practice placed the residents at risk for contaminated food, illness and discomfort. Findings included: - During an observation on 06/02/25 at 02:51 PM, there was an abundance of flies throughout the kitchen area. Further observation revealed no methods to prevent or eradicate the insects. During an observation on 06/03/25 at 12:20 PM, observation revealed flies throughout the kitchen and dining room area. During an observation on 06/04/25 at 09:13 AM, the west door that led from outside into the kitchen would not close completely without force. During an observation on 06/04/25 at 09:20 AM, the east dining room door that led directly into the courtyard had a significant gap at the bottom large enough to allow pests and/or rodents to enter the dining room. During an observation on 06/04/25 at 09:25 AM, an outer…
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 before2025-06-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 36 residents with 14 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to ensure dignified care for Resident (R)28, when staff failed to cover the resident while receiving care when staff entered and exited his room. This placed the resident at risk for embarrassment and decreased psychosocial well-being. Findings included: - A review of R28's Electronic Medical Record (EMR) revealed a diagnosis of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS noted he required staff assistance with toileting. R28's Urinary Incontinence/Indwelling Catheter Care Area Assessment dated 04/17/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-04 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 36 residents. The sample included 14 residents with one sampled for dialysis (a procedure where impurities or wastes were removed from the blood) review. Based on observation, interview, and record review, the facility failed to complete a Significant Change Minimum Data Set assessment for Resident (R) 31 when the resident started dialysis. This deficient practice placed the resident at risk for unidentified care needs after a significant change in health status. Findings: - R31's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. R31's 02/21/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R31 was not on dialysis services at that time. R31's 05/09/25 Quarterly MDS documented a BIMS of 13. The MDS noted R31 was on dialysis services at that time. R31's Care Plan, dated 05/09/25, documented R31 had dialysis treatment and instructed staff to coordinate…
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 before2025-06-04 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 36 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set for Resident (R) 2. This placed the resident at risk for unidentified care needs. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety (class of medications that calm and relax people), depressive disorder (major mood disorder which causes persistent feelings of sadness), obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe enough to cause marked distress, consume considerable time, or significantly interfere with the resident's occupational, social, or interpersonal functioning), and dementia (a progressive mental disorder characterized by failing memory and confusion). R2's 10/28/24…
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 before2025-06-04 · 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 reported a census of 36 residents with 14 residents sampled including one resident reviewed for positioning. Based on observation, interview, and record review, the facility failed to ensure appropriate wheelchair positioning for Resident (R)23, regarding the positioning of her feet on the foot pedals. This placed the resident at risk for accidents and decreased comfort. Findings included: - Review of R23's Electronic Medical Record (EMR) revealed a diagnosis of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). R23's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS noted R23 was independent with mobility in her wheelchair and had no limitation in range of motion (ROM). The Functional Abilities Care Area Assessment (CAA), dated 07/01/24,…
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 · D2025-06-04 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 36 residents. The sample included 14 residents with one sampled for dialysis (a procedure where impurities or wastes were removed from the blood) review. Based on observation, interview, and record review, the facility failed to provide the necessary dialysis assessment, care, and services for Resident (R) 31. This deficient practice had the risk of adverse outcomes and dialysis complications for R31. Findings: - R31's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. R31's 02/21/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R31 was not on dialysis services at that time. R31's 05/09/25 Quarterly MDS documented a BIMS of 13. The MDS noted R31 was on dialysis services at that time. R31's Care Plan, dated 05/09/25, documented R31 had dialysis treatment and instructed staff to coordinate care in collaboration with the dialysis center. The plan…
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 · Fcited before2023-08-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to properly store, prepare and distribute food under sanitary conditions to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility. Findings included: - During the initial tour of the kitchen on 08/30/23 at 01:05 PM, the following areas of concern were noted: 1. The bottom shelf of the cup rack contained dried food debris. 2. Four plastic pitchers had a brownish stain on the inside. 3. A reach-in refrigerator had an open gallon paper container of potato salad which was undated. 4. The shelf below the microwave had dried food debris. 5. Two reach in freezers had food debris on the bottom shelves. 6. Two coffee pots were heavily stained on the inside glass of the pots with a build-up of dried on coffee on the spout and handle of the pots. 7. A large pork loin was in a dry sink thawing inappropriately. 8. The spice shelf had a layer of dust. 9. The inside of the microwave had multiple areas…
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 · F2023-08-31 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 32 residents. Based on observation, interview, and record review, the facility failed to ensure sanitary catheter care for two Residents (R)10 and R87, failed to sanitize a nasal inhaler and utilize proper hand hygiene for this task for R15 and dietary staff failed to don personal protective equipment prior to entry to R30's room who was in isolation due to active COVID infection. Findings included: - Observation, on 09/29/23 at 09:26 AM, revealed Dietary Staff BB entered Resident (R)30's room which required personal protective equipment (PPE) due to the resident's positive COVID-19 status and isolation protocol, without donning (putting on) PPE, as instructed, on the signage near the door to the resident's room. Interview, on 09/29/23 at 09:28 AM, with Dietary Staff BB, revealed she did not know she needed to wear PPE as she delivered breakfast to the resident. Interview on 09/29/23 at 11:20 AM, with Licensed Nurse G, confirmed R 30 was in isolation for COVID and he would expect all staff to don and doff PPE. Interview, on 09/31/21 at 11:40 AM,…
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 · F2023-08-31 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
The resident reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. Findings included: - During the initial tour of the kitchen on 08/30/23 at 01:05 PM, the following area of concern was noted: The floor throughout the kitchen had areas which contained a dried, liquid, sticky substance. The parameter of the floor had a heavy build-up of dirt and grime. On 08/30/23 at 03:18 PM, Administrative Staff A stated it was the expectation the kitchen floor would be kept clean at all times. The facility policy for Sanitation, revised 10/2008, included: The food service area shall be maintained in a clean and sanitary manner. The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff.
Show the remaining 14 citations
- Potential for harm · E2023-08-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 32 residents with 16 selected for review. Based on observation, interview, and record review, the facility failed to review and revise the care plan for Resident (R)15 to include use of an arm immobilizer after the resident had a fractured humerus and inability to utilize a walker, R25 for chin hair removal, R18 for toilet times and use of bedpan, and R 23 for use of foot pedals on her wheelchair. Findings included: - Review of Resident (R)15's Physician Order Sheet, dated 08/26/23, revealed diagnoses included fractured humerus (bone between shoulder and elbow), chronic obstructive lung disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease, and heart failure. The admission Minimum Data Set (MDS) dated [DATE] assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The resident had limitation in functional range 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 · E2023-08-31 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 32 residents with 16 residents selected for review, which included five residents reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to ensure five residents (R)11, R15, R2, R25 and R26 had facial hair groomed appropriately and one resident, R25 had clean and trimmed fingernails. Findings included: - Review of Resident (R)11's electronic medical record, revealed diagnoses included dysarthria (difficulty speaking due to muscle weakness), hypertension (elevated blood pressure), and epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set, dated 08/02/23, assessed the resident with normal cognitive function and required limited assistance with personal hygiene. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/02/23, assessed the resident was dependent with transfers. The Care Plan, revised 08/21/23, instructed staff to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 32 residents with 16 residents sampled, including three residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)25, when staff failed to close the blinds while providing peri-care (cleansing of the genitals), R 10, when staff failed to provide dignity as two staff opened and closed the door to his room while he was exposed from the mid chest to his ankles, and R26, when the resident had his abdomen exposed in the dining room, common living area. Findings included: - The Physician Order Sheet (POS), dated 08/23/23, documented Resident (R) 25 had diagnoses which included: anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), panic (sudden uncontrollable fear or anxiety, often causing wildly unthinking behavior) and cerebral infarction ((CVA [stroke] sudden death of brain cells due to lack of oxygen caused by impaired blood flow 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 before2023-08-31 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 32 residents with 16 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)25, regarding anti-psychotic medications (class of medications used to treat psychosis and other mental emotional conditions). Findings included: - Review of Resident (R)25's electronic medical record (EMR) included diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain disorder (a mental and behavioral disorder), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness emptiness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · 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 32 residents with 16 residents sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one Resident (R)32, regarding pain. Findings included: - Review of Resident (R)32's electronic medical record (EMR) included a diagnosis of fractured ribs (broken ribs). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He reported frequent pain with worse pain in past five days being five out of a one to ten pain assessment tool. Pain did affect his sleep but did not affect his day to day activities. He received as needed (PRN) pain medications. The Pain Care Area Assessment (CAA), dated 08/21/23, documented the nursing staff would monitor the resident for pain and work on finding effective pain management interventions, including medication and non-medical options for pain. The care plan, dated…
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 before2023-08-31 · 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 32 residents with 16 residents sampled, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards for one Resident (R)23, regarding the lack of foot pedals on her wheelchair. Findings included: - Review of Resident (R)23's electronic medical record (EMR) included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She required extensive assistance of one staff for locomotion on the unit. She had no impairment in her functional range of motion (ROM) and used a wheelchair for locomotion. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 07/26/23, did not trigger. The Quarterly MDS, dated 04/27/23, documented the resident had a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 reported a census of 32 residents with 16 residents sampled including one resident reviewed for bowel and bladder. Based on observation, interview, and record review, the facility failed to develop and implement an effective individualized toileting program to maintain as much bladder function as possible for one Resident, (R)18. Findings included: - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of overactive bladder (OAB--causes a frequent and sudden urge to urinate). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. She required limited assistance of one staff for toileting and was frequently incontinent of urine. She lacked a toileting program. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/19/23, documented the resident required limited assistance with toileting and was frequently incontinent.…
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 · D2023-08-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 35 residents with 16 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)15, received laboratory blood monitoring as ordered by the physician. Findings included: - Review of Resident (R)15's Physician Order Sheet, dated 08/26/23, revealed diagnoses included chronic obstructive lung disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease, and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The resident received seven days of insulin injections, antipsychotic (medication to manage major mental health disorders,)…
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 · Fcited before2022-03-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 20 residents. Based on observation and interview, the facility failed to ensure a two-inch air gap existed between the two water drainage pipes on the ice machine and the sewer drain to prevent the backflow of contaminated drain water up into the ice machine to prevent the spread of food borne illness to the residents. Findings included: - Observation, on 03/15/22 at 2:00 PM, environmental tour of the kitchen areas revealed an ice machine with two drainage pipes. The end of the upper most drainage pipe elbowed into a cylinder shaped attachment and to the sewer pipe. The lower ice machine drainage pipe was positioned in the large opening of the sewer pipe. Interview, on 03/15/22 at 2:15 PM, with maintenance staff U, stated the ice machine was installed last year. Maintenance staff U stated he thought the sewer water would not back flow into the machine as the pressure from the sewer would not exceed the pressure from the pipes leading from the ice machine. Maintenance staff U confirmed the drainage pipes from the ice machine could be exposed 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.
- Potential for harm · Dcited before2022-03-16 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 20 residents with 15 residents selected for the sample. Based on interview, observation, and record review, the facility failed to complete a significant change Minimum Data Set (MDS), for one Resident (R)#6 for initiation of hospice care services. Findings included: - Review of Resident (R)6's electronic medical record (EMR), under the Med Diag tab, included the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (HTN) (elevated blood pressure) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness emptiness). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She required extensive assistance of one staff for transfers,…
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 before2022-03-16 · 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 20 residents with 15 selected for review. Based on interview and record review, the facility failed to complete a comprehensive care plan for one resident (R)7 to ensure the development of goals, interventions, and treatments to meet the needs of this resident. Findings included: - Review of resident (R)7's Physician Order Sheet, dated 01/24/22, revealed diagnoses of atrial fibrillation(rapid, irregular heart beat), chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing,) Barrett's esophagus(a condition caused by inflammation and damage to the lining of the esophagus) chronic kidney disease, dysphagia (difficulty swallowing,) and pacemaker for heart failure. The admission Minimum Data Set, (MDS), dated [DATE], assessed the resident with normal cognitive function, required extensive assistance of two persons for activities of daily living (ADL) and had impairment in…
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 · D2022-03-16 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 20 residents with 15 residents selected for review, including one resident reviewed for discharge. Based on interview and record review, the facility failed to complete a discharge summary for one Resident (R)22, following discharge from the facility. Findings included: - Review of the resident's electronic medical record (EMR) under the Med Diag tab, included the following diagnoses: spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities) and type II diabetes mellitus (DM--when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The admission Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE] from an acute care hospital. The resident expected to be discharged to the community. The Return to Community Referral Care Area Assessment (CAA), dated 12/28/21, documented the resident was a short term resident with plans to return 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 before2022-03-16 · 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 reported a census of 20 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to ensure dressing change to one resident (R)11 skin tear in a sanitary manner to promote healing and prevent infections. Findings included: - Review of resident (R) 11's Physician Order Sheet, dated 02/01/22, revealed diagnoses included hypertension (elevated blood pressure,) , glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow) and falls. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident had normal cognition. The resident had severely impaired vision. The resident had no impairment in functional range of motion in her upper and lower extremities. The Falls Care Area Assessment (CAA), dated 01/07/22, assessed the resident had falls while living at home within the last two to six months, and was virtually blind in both eye due to glaucoma, which increased her risk for falls. The resident…
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.
- No harm found · C2025-06-04 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 36 residents. Based on record review and interview, the facility failed to display accurate and identifiable staffing information, which contained the actual nursing hours worked. Findings included: - Review of the facility's Daily Staffing Sheets, from 05/01/25 through 06/02/25, revealed the actual hours worked had not been completed on the daily staffing sheets. On 06/04/25 at 07:11 AM, Administrative Nurse D verified the actual hours worked had not been filled in on the daily staffing sheets, as required. The facility did not provide a policy regarding the accurate completion of the Daily Staffing Sheets.
“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
$14,069 in federal fines across 1 penalty.
- $14,069 — penalty dated 2025-03-20
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to AMERICARE SENIOR LIVING — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.6 | -0.6 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 4 of 5 | 3.6 | +0.4 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 22 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| R H MONTGOMERY PROPERTIES, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/02/2003 |
| RICHARD H. MONTGOMERY III REVOCABLE TRUST DATED APRIL 8, 1996 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2013 |
| MONTGOMERY, ANNA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2013 |
| MONTGOMERY, RICHARD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | NO PERCENTAGE PROVIDED | since 01/15/2003 |
| HATLESTAD, STEVEN | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2002 |
| SCHADE, KYLE | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/01/2021 |
| REED, JENNIFER | Individual | W-2 MANAGING EMPLOYEE | — | since 02/08/2019 |
| REIKER, JAMES | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2002 |
| AMERICARE SYSTEMS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2002 |
| CROSSON, CLAY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/29/2001 |
CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $208K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 175224. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-04, 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.