No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Kansas Christian Home

1035 SE 3rd Street, Newton, KS 67114 · Non profit - Church related · 54 certified beds · (316) 283-6600 Medicare & Medicaid certified

Call the home — (316) 283-6600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609) — most recent May 20261 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
720 Medical Center Dr · (316) 284-5151 · Call to confirm hours
Pharmacy
215 S Pine St · (316) 281-7902 · Call to confirm hours
Grocery
Dillons1.0 mi
1410 S Kansas Ave · (316) 284-3720 · Call to confirm hours
Park
700 Washington Rd · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 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 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.4%17.9%15.4%better
Long-stay residents who lose too much weight3.5%4.9%5.4%better
Long-stay residents with a catheter left in their bladder2.6%1.6%0.9%worse
Long-stay residents with a urinary tract infection3.0%2.9%2.0%worse
Long-stay residents with depressive symptoms0.0%6.5%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.7%4.3%3.3%worse
Long-stay residents whose ability to walk worsened8.7%16.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.7%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers3.5%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control6.6%22.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.4%18.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents given the seasonal flu vaccine57.1%73.8%79.4%worse
Short-stay residents rehospitalized after admission29.1%22.4%22.6%worse
Short-stay residents with an outpatient ER visit15.3%11.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.481.801.67worse
Long-stay outpatient ER visits per 1,000 resident days2.312.131.80worse

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

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

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

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

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.

50.7% 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 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.7%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
74.2%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 74.2% 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 31 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 0.37 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 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.7%CMS range 40.3–61.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 8.1–15.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge74.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge71.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge71.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.9%CMS range 4.6–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.67
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.69
Aide hours/ resident / day
4.09
Total nurse hours/ resident / day
0.36
RN hoursweekends
50.9%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 54 beds and averages 48.5 residents a day — about 90% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.63 hrs/resident/day on weekends vs 4.28 on weekdays — 15% thinner on weekends. RN hours go from 0.79 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

13
deficiencies at the latest standard inspection (2026-05-14)
6
at the previous standard inspection (2024-07-03)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · Gcited before2024-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 46 residents. The sample included three residents reviewed for neglect. Based on observation, interview, and record review, the facility failed to protect dependent Resident (R)1 from harm, when staff did not follow the resident's care plan, which instructed nursing staff to utilize a slide board (assist users and caregivers in the safe transfer from wheelchair to bed) to transfer the resident. On 10/18/24 at approximately 12:00 PM, Licensed Nurse (LN) G requested assistance from Certified Medication Aide (CMA) M when the resident requested to use the restroom. Certified Medication Aide (CMA) M entered the resident's room and observed the resident sitting in her wheelchair. CMA M offered to transfer R1 from her wheelchair to the bed to use the bed pan per her care plan, but the resident requested to use the toilet in the bathroom. CMA M propelled the resident to the bathroom, placed a gait belt around the resident's body, wrapped her arms around the resident, and completed a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-05-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included:- During an initial tour of the kitchen on 05/12/26 at 10:07 AM, the following areas of concern were noted: 1. The reach-in freezer had food debris on the bottom shelf. 2. The two-doored reach-in refrigerator had dried-on fluids on the bottom shelf. 3. The bottom shelf of the preparation table, holding clean pots and pans, had food debris. 4. There were 13 discolored cutting boards with deep grooves throughout. 5. The trash can by the dish washing sink had dried-on food and fluids on the lid. 6. An unopened box containing 12 packages of eight hot dog buns each, rested directly on the floor of the walk-in freezer. 7. The floor in the dry supply room was completely worn down to the subflooring in several areas of the room. On 05/14/26 at 07:15 AM, Dietary Staff BB confirmed the noted areas were in need of cleaning or repair. The facility policy for…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received assistance with activities of daily living (ADL) including facial hair removal for Resident (R) 21 and assistance with nail care for R45, R6, R16, and R18. Findings included:1. R21's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and needed assistance with personal care. R21's 08/20/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, which indicated severely impaired cognition. R21's MDS documented that she had no rejection of care during the observation period. R21's MDS documented that she required maximal assistance with personal hygiene. R21's 08/25/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R21 is a new admission after hospital stay. She has been working with therapy to improve her ability. She often overestimates her ability…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure informed consent including purpose, risks versus benefits, and expected therapeutic benefits for the use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), anti-anxiety (medication used to treat symptoms of anxiety, hypnotics (a class of medications used to induce sleep) and antidepressant (a class of medications used to treat mood disorders) medications for R4. This placed the resident at risk for adverse side effects of the medications and uninformed decisions. Findings included:- R4's Electronic Medical Record (EMR) documented the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) and obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 38 received the opportunity to participate in the care planning process when staff failed to invite R38, or their responsible party to the care pan meetings. Findings included:- R38's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R38's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R38's MDS documented that she required maximal assistance with activities of daily living (ADLs). R38's MDS documented that she had no behaviors. R38's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 02/13/26, documented R38 participated with restorative programs. She made some improvements over the look back…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a stop date for an as needed (PRN) antianxiety medication for R4 and R3's lorazepam (an antianxiety medication). Findings included:1. R4's Electronic Medical Record (EMR) documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R4's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. R4 received antianxiety (medication used to treat symptoms of anxiety) during the assessment period. R4's Psychotropic Drugs Care Area Assessment (CAA), dated 05/30/25, documented R4 received several psychotropic medications which the pharmacy consultant and physician reviewed monthly, to maintain therapeutic uses. R4's Quarterly MDS, dated [DATE], documented a BIMS score of seven, indicating severe cognitive impairment. R4 received antianxiety medication during the assessment…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency (SA) within the required time frame of the alleged incident(s) as required for Resident (R) 59. Findings included:- R59's Electronic Medical Record (EMR) documented diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), and encephalopathy (a broad term for any brain disease that alters brain function or structure). R59's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R59's MDS documented no behaviors. R59's Communication Assessment (CAA), dated 07/02/25, documented R59 had dementia, and hearing loss bilaterally, R59 did not wear hearing aids. R59 spoke clearly, he is generally understood and understands others, he does sometimes have more difficulty with communication when he is tired and can be confused at times. R59's Quarterly MDS, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and implement resident-centered fall interventions for Resident (R) 4, who was at risk for falls. Findings included:- R4's Electronic Medical Record (EMR) documented a diagnosis of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R4's Annual Minimum Data Set (MDS), dated [DATE], documented R4 had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. He had one non-injury fall and one injury (except major) fall since his prior assessment. R4's Falls Care Area Assessment (CAA), dated 05/30/25, documented the resident was at a high risk for falls, with two falls since his prior assessment. R4's Quarterly MDS, dated [DATE], documented he had a BIMS score of seven, indicating severe cognitive impairment. He had two or more non-injury falls since his prior assessment. R4's Care Plan, revised 03/02/26, instructed staff to utilize a gait…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor Resident (R) 6's physician-ordered fluid restriction. Findings included: -R6's Electronic Medical Record (EMR) included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), chronic pain syndrome, nutritional deficiency, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, chronic kidney disease, personal history of urinary calculi (kidney stones), and urinary tract infection (UTI-an infection in any part of the urinary system). R6's Significant Change Minimum Data Set (MDS), dated [DATE], documented that R6 had staff assessment of moderately impaired cognition, continuous inattention, and disorganized thinking behavior, along with hallucinations (sensing things while awake that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility's pharmacy consultant failed to report irregularities to the resident's physicians, the facility administrator and the director of nursing regarding the lack of stop dates for as needed (PRN) antianxiety medication for Resident (R)4 and R3's PRN lorazepam (an antianxiety medication). Findings included:1. R4's Electronic Medical Record (EMR) documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R4's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. R4 received antianxiety (medication used to treat symptoms of anxiety) during the assessment period. R4's Psychotropic Drugs Care Area Assessment, (CAA), dated 05/30/25, documented R4 received several psychotropic medications which the pharmacy consultant and physician reviewed monthly, to maintain therapeutic uses. R4's Quarterly…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure collaboration between the facility and hospice which included a hospice (a program that gives special care to people who are near the end of life) service visit frequency, medications, medical equipment, and the resident representative's preference for Resident (R) 3. Findings included: -R3's Electronic Medical Record (EMR) included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hearing loss, need for assistance with personal care, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), senile degeneration of the brain (progressive, age-related decline in brain function), and fracture (broken bone) of left femur (thigh bone). R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2026-05-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, observation, and record review, the facility failed to ensure adequate hand hygiene eye medication administration for Resident (R) 47 and during a dressing change for R45. Findings included:1. On 05/12/26 at 04:03 PM, Certified Medication Aide (CMA) T applied one glove to her left hand without performing hand hygiene. CMA T administered one drop of R47's timolol ophthalmic (lower elevated eye pressure) eye drops into each eye. CMA T held onto the bottle of eye drops with her ungloved right hand and then used her left hand to hold R47's eyelid open. CMA T used the same tissue to wipe each eye after the eye drop was administered with her ungloved right hand. On 05/12/26 at 04:10 PM, CMA T reported that she did not realize that she had only worn one glove and she should have used a glove on each hand after she washed in her hands. CMA T reported that she thought she used a different tissue. 2. On 05/13/26 at 07:32 AM, Licensed Nurse (LN) H removed the R45's dressing from his left heel with her right hand and cleansed the open area. LN H then removed R45's 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to offer and provide or obtain an informed declination for the pneumococcal vaccine (vaccine designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) for Resident (R) 4. Additionally, the facility failed to offer and provide or obtain informed declination for the influenza vaccine (vaccine designed to prevent highly contagious viral infection) form to R6. Findings included:1. R4's Electronic Medical Record (EMR) lacked documentation of a pneumococcal vaccine being administered after responsible party wrote wants all near the column of vaccines that were recommend on the Vaccine(s) Declination form COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus), Influenza Vaccine, Pneumococcal Vaccine, and Shingles Vaccine (a vaccines to prevent a viral infection that causes a painful, blistering rash). None of the vaccines had a check mark to decline in box under the declination column. 2. R6's EMR lacked documentation of an influenza vaccine being…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to offer and provide or obtain an informed declination for the COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus) for Resident (R) 6 and R21. Findings included:1. R6's Electronic Medical Record (EMR) lacked documentation of a COVID-19 vaccine being offered since 2022. 2. R21's EMR lacked documentation of a COVID-19 vaccine being offered since 2021. On 05/14/26 at 10:45 AM, Administrative Nurse F produced the requested COVID-19 vaccine forms and reported that she could not locate a recent COVID-19 offered and provided or obtained an informed declination for R6 and R21. On 05/14/26 at 10:50 AM, Administrative Nurse D reported she expected all the residents to have the COVID-19 Vaccine offered. Administrative Nurse D reported she expected the residents EMR to have the information if the vaccines were offered/administered or declined. The facility did not provide a policy on COVID-19 Vaccine.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-07-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible foodborne illness for the residents in the facility. Findings included: - Observation, on 07/01/24 at 08:45 AM, revealed the following areas of concern in the dry goods pantry: One unsealed 25 pound (lbs.) bag of rice and one unsealed open 50 lbs. bag of flour in the dry goods pantry. One opened five lbs. container of teriyaki sauce with an expiration date of 04/21/24. One gallon of Worcestershire sauce, with no opened date and no expiration date, with approximately one-fourth of the gallon remaining. Observation, on 07/01/24 at 08:50 AM, revealed 12 boxes of frozen food stored directly on the floor of the walk-in freezer. Interview, on 07/01/24 at 11:30 AM, with Dietary Staff BB revealed the delivery of frozen foods came on Friday, and confirmed staff should place the items on shelves in the freezer. Observation, on 07/02/24 at 02:48 PM, during the environmental tour with Dietary Staff BB,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-03 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to conduct annual performance reviews for two of five Certified Nurse Aide/Medication Aides reviewed, to ensure the residents received adequate cares. Findings included: - Review of five Certified Nurse/Medication Aide's (CNA/CMA) employment records revealed the facility did not complete two of the five CMA/CNA's annual performance reviews, as follows: 1. CMA/CNA R, hired on 09/15/1995, with the most recent Annual Performance Evaluation, dated 08/20/22 (22 months past due). 2. CMA/CNA S, hired on 08/21/18, with the most recent Annual Performance Evaluation, dated 11/14/22 (19 months past due). On 07/03/24 at 12:44 PM, Administrative Staff D stated CMA/CNAs employed more than one year should have an annual performance evaluation. She verified the above findings and reported that all nursing staff were available to assist all residents of the facility. The facility lacked a policy to address the completion of an annual performance evaluation/review for CMA/CNA staff…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-03 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 47 residents. Based on observation, interview and record review, the facility failed to monitor and serve food at safe palatable (pleasant to taste) temperatures as required. Findings included: - During an interview on 07/01/24 at 09:19 AM, Resident (R)31 revealed the food served to him was not hot. During an interview on 07/01/24 at 10:08 AM, R10 revealed he ate his meals in his room, per his choice, and the food was usually served cold. During an interview on 07/01/24 at 10:15 AM, R43 revealed the food was cold when he received it. Observation, on 07/02/24 at 11:07 AM, revealed dietary staff as they prepared food carts for lunch service to the 300 hall. A tray containing 11 slices of cheesecake sat on top of the food cart. Observation, on 07/02/24 at 11:35 AM, revealed Dietary Staff CC took the broccoli out of the steam oven and did not take the temperature, until requested. The temperature was 132 degrees Fahrenheit (F). Dietary Staff CC stated she did not know broccoli required a temperature before serving and returned it to the steamer. Dietary…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 identified a census of 47 residents, which included 16 residents sampled and reviewed for care plan development. Based on interview, observations, and record review, the facility failed to develop a comprehensive person-centered care plan for one resident. Resident (R) 35 comprehensive person-centered care plan was not completed in a timely manner of 21 days from admission. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. Findings included: - R35's Electronic Health Record (EHR) revealed diagnoses that included nontraumatic chronic subdural hemorrhage (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain), muscle weakness, and repeated falls. The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident had a total…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-03 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 47 residents with 16 residents included in the sample. Based on observation, record review, and interview, the facility failed to review and revise the care plan for one Resident (R)1 regarding weekly weights and interventions to prevent further weight loss. Findings included: - Review of R1's diagnoses from the Electronic Health Record (EHR) documented, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diverticulitis (inflammation of the diverticulum, in the colon, which caused pain and disturbance in bowel function), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R1…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47 residents with 16 sampled. Based on observation, interview, and record review, the facility failed obtain daily weights as ordered on 03/28/24 for cognitively impaired Resident (R) 1, who had an identified weight loss. This deficient practice had the potential to negatively affect the resident's physical well-being. Findings include: - Review of R1's diagnoses from the Electronic Health Record (EHR) documented, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diverticulitis (inflammation of the diverticulum, in the colon, which caused pain and disturbance in bowel function), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-09-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 52 residents. Based on observation and interview, the facility failed to store prepare and serve foods under sanitary conditions to the residents of the facility. Findings included: - On 09/21/22 at 03:11PM, the initial tour of the main kitchen, revealed the following areas/items of concerns: The following items were found to be expired: An open bag of powder sugar, undated. Two opened bags with pasta, undated. One opened large bag of bacon bits, undated, with use by date printed as 09/01/22. One opened large container of sour cream, with a use by date of 09/08/22. One, five-pound bag of grated Parmesan and [NAME] cheese, with use by date of 08/31/22. One five-pound bag of grated Swiss cheese with a use by date of 08/31/22. A small, wrapped package of Oreo cookies with a use by date of 08/27/22. One 24-ounce container with cheese pimento spread with a use by date of 08/11/22. Three 32-ounce containers of ketchup with a use by date of 09/14/22. Inside of a freezer, inside of an…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-09-28 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 52 residents which included five residents reviewed for vaccine administration. Based on record review and interview, the facility failed to ensure residents who declined the influenza, pneumococcal and covid-19 vaccinations were provided with the benefits verses risk for these vaccines and had a system in place for acknowledgement of the benefit verses risk for declination of these vaccines. Findings included: - Review of Resident (R)22's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident declined the Influenza vaccine, and fourth Covid-19 booster. Review of R 15's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident refused the fourth Covid-19 booster. Review of R 18's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed the resident refused the Covid-19 vaccine. Review of R 36's electronic medical record Preventive Health Care, and Vaccine Spread Sheet as of 09/22/22 revealed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-28 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 52 residents with 16 selected for review. Based on observation, interview and record review, the facility failed to develop a baseline care plan for one newly admitted sampled resident (R)151, to include the resident's physical disability of right below knee amputation status. Findings included: - Review of Resident (R)151's undated Physician Orders, revealed diagnoses included right below knee amputation, traumatic subdural hematoma (bleeding in the brain), and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) was in process. The Matrix (a form that the facility documents resident status) dated 09/22/22, indicated the resident had two unstageable pressure ulcers. The Baseline Care Plan, dated 09/09/22, (resident admitted to the facility 09/16/2), instructed staff the resident required extensive assistance for toileting. Staff instructed to assist as needed as the resident had impaired gait and was a fall…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-28 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 52 residents with 16 selected for review. Based on observation, interview and record review, the facility failed to review and revise one sampled dependent resident (R) 27's care plan to include interventions and treatment for her left heel blister. Findings included: - Review of Resident (R)27's Physician Order Sheet, dated 09/20/22, revealed diagnoses included protein calorie malnutrition, schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), major mood disorder, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), kyphosis ( curvature of the spine), and dementia(progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with modified independent ability in cognition for decision making. The resident required extensive assistance of two…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 52 residents with sixteen selected for review which included one resident reviewed for hospice services and one resident reviewed for skin issues. Based on observation, interview and record review, the facility failed to coordinate wound care with the hospice provider for the one resident (R)151 and failed to provide a protective foot device for the one resident (R)27. Findings included: - Review of Resident (R)27's undated Physician Orders, revealed diagnoses included right below knee amputation, traumatic subdural hematoma (bleeding in the brain), and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) was in process. The Matrix (a form that the facility documents resident status) dated 09/22/22, indicated the resident had two unstageable pressure ulcers. The Baseline Care Plan, dated 09/09/22, (resident admitted to the facility 09/16/2) instructed staff the resident required extensive assistance for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 52 residents with 16 selected for review which included two residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to provide recommended additional nutritional services for one of the two residents (R)12 reviewed for nutrition. Findings included: - Review of Resident (R)12's Physician Order Sheet, undated, revealed diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), anxiety mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder and gastroesophageal reflux disease (GERD backflow of stomach contents to the esophagus). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a BIMS (brief interview for mental status score) of 13 (normal 13-15). The resident required supervision for eating and had impairment in functional…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-28 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 52 residents with 16 selected for review including five reviewed for unnecessary medications. Based on record review and interview, the facility failed to accurately monitor abd hold an antihypertensive medication (for high blood pressure) when the blood pressure was out of the physician ordered parameters for Resident (R)26 and failed to accurately monitor and notify the physician for R47 when the pulse was out of physician ordered parameters with an anti-hypertensive medication. Findings included: - The Face Sheet for Resident (R)26 included a diagnosis of hypotension (low blood pressure). The Care Plan dated 08/17/22 for R26 included he was at risk for medication side effects and included the medication midodrine (used to treat low blood pressure), which has a Black Box Warning (the strongest form of warning required by the Food and Drug Administration that indicates an increased risk of serious adverse reactions associated with the use of a medication). The Care 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
FRIENDS OF KANSAS CHRISTIAN HOME INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/21/2025
BIRKET, SAMUELIndividualCORPORATE DIRECTORsince 01/01/2025
BUNTON, PATRICIAIndividualCORPORATE DIRECTORsince 07/01/2022
DUBOVICH, DAVIDIndividualCORPORATE DIRECTORsince 07/01/2022
FLINT, CALEBIndividualCORPORATE DIRECTORsince 07/01/2023
GALLOWAY, LINDAIndividualCORPORATE DIRECTORsince 07/01/2021
HAMLIN, GREGIndividualCORPORATE DIRECTORsince 01/01/2025
HARLAND, JUSTINIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/15/2024
SCHWARZ, DEBRAIndividualCORPORATE DIRECTORsince 07/01/2023
TANGEMAN, TODDIndividualCORPORATE DIRECTORsince 07/01/2022
GLEASON, ROBERTIndividualCORPORATE OFFICERsince 07/01/2018
HISS, ROBERTIndividualCORPORATE OFFICERsince 07/01/2021
FLEMMING, DONNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2013

CMS files one row per role, so the 17 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$5.9M
Net patient revenuemost recent cost report
-25.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 57%Medicare 9%Other / private 35%

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

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

Cost & finances

$440per resident / day
operating cost
$13,364per month
≈ monthly operating cost
$349per day
avg. revenue, all payers

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

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175467. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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.

What to do next