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Good Samaritan - Decatur County

108 E Ash Street, Oberlin, KS 67749 · Non profit - Corporation · 45 certified beds · (785) 475-2245 Medicare & Medicaid certified

Call the home — (785) 475-2245 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 20243 actual-harm citations$20,207 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $20,207 in federal fines (most recent 2023-09-11)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (61%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
111 W Main St · (785) 678-2350 · Call to confirm hours
Pharmacy
Grocery
119 W Commercial St · (785) 475-2952 · Call to confirm hours
Park
Oberlin - Sappa · Typically dawn to dusk
Place of worship
404 N York Ave · (785) 475-2053

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 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 4 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.

Overall rating2★
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 increased28.8%17.9%15.4%worse
Long-stay residents who lose too much weight16.9%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder6.8%1.6%0.9%worse
Long-stay residents with a urinary tract infection0.0%2.9%2.0%better
Long-stay residents with depressive symptoms1.9%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury10.8%4.3%3.3%worse
Long-stay residents whose ability to walk worsened24.7%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication30.8%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers6.1%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control19.8%22.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table16.3%18.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Long-stay hospitalizations per 1,000 resident days0.921.801.67better
Long-stay outpatient ER visits per 1,000 resident days2.932.131.80worse

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

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

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

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

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

0.23U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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

Staffing

1.73
RN hours/ resident / day
0.24
LPN hours/ resident / day
2.38
Aide hours/ resident / day
4.35
Total nurse hours/ resident / day
0.99
RN hoursweekends
60.9%
Total nursing turnover
83.3%
RN turnover

How full it usually is: this home is certified for 45 beds and averages 18.7 residents a day — about 42% occupied, or roughly 26 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.35 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.62 hrs/resident/day on weekends vs 4.64 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 2.03 to 0.99 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above 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

7
deficiencies at the latest standard inspection (2025-11-17)
8
at the previous standard inspection (2023-11-30)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2024-02-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 31 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from abuse and/or neglect. On 02/09/24, Certified Nurse Aide (CNA) M forcefully grabbed R1's wrist, took the glass of orange juice out of R1's hand, and slammed the orange juice on the table. Then CNA M aggressively grabbed R1's wheelchair to start moving her, and R1 put her foot down on the floor. CNA M yelled at R1 and aggressively placed R1's feet on the foot pedals. Social Services X attempted to intervene, but CNA M ignored Social Services X and continued to try and wheel R1 out of the dining room. CNA M treated R1 in a manner that did not uphold the resident's sense of self-worth and individuality. This deficient practice placed R1 at risk for physical harm, pain, and mental anguish. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion),…

    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
  • Actual harm · G2023-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 30 residents with three reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure interventions were implemented to prevent Resident (R) 1 from falling out of bed and failed to ensure intervention in place to prevent injuries for R1 who had multiple falls from her bed. As a result, R1 fell out of bed and sustained an acute left hip fracture. This deficient practice also placed R1 at risk for further falls and injuries. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated 06/22/23, documented R1 had a Brief Interview for Mental Status score of three, which indicated severe cognitive impairment. The MDS documented R1 required…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2022-07-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 13 residents of which five were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interview, the facility failed to identify the risk for pressure injuries and implement preventive interventions for Resident (R)8 who had pressure areas on her buttocks and had a decline in health. As a result, R8 developed a pressure injury to her left heel, which progressed to an open wound. The facility further failed to ensure weekly monitoring of skin conditions in order to assess wound status including wound bed, healing, and effectiveness of treatments for R7 and failed to review and offer treatment options to R31. This deficient practice placed those residents at risk for delayed healing or worsened wounds. Findings included: - The Electronic Medical Record (EMR) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-11-17 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 18 residents. Based on the interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30) indicated the facility did not have licensed nurse coverage 24 hours a day on the following dates:07/07/24 (SU), 07/27/24 (SA), 07/28/24 (SU)08/11/24 (SU)09/29/24 (SU).Review of the facility's daily nursing staff coverage revealed the facility had licensed nurse coverage 24 hours a day on the above dates, and revealed the facility had adequate licensed nurse coverage.On 10/21/25 at 08:37 AM, Administrative Staff A stated the human resource staff was responsible for submitting the PBJ during that period of time, and she no longer worked for the facility.The facility's Reporting Direct Care Staffing Information (PBJ) Policy, revised May 2024, documented that complete and accurate direct care staffing information would be…

    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 · F2025-11-17 · tag F0755 — failed to provide safe pharmacy services — widespread
    Provide 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

    The facility had a census of 18 residents. The sample included eight residents. Based on observation, interview, and record review, the facility, in coordination with the licensed pharmacist, failed to provide a system of medication records that enabled periodic, accurate reconciliation and accounting for all resident medications when the emergency medication kit (E-Kit) was unlocked in the medication room. The facility staff failed to label and date Resident (R) 6's Insulin aspart (rapid acting) insulin (a hormone that lowers the level of glucose in the blood) pen (a device for giving insulin shots). This placed the residents at risk for being charged for a medication not administered to them from the e-kit. Findings included:- On 09/23/25 at 08:50 AM, during inspection of the facility medication room with Licensed Nurse (LN) G, revealed that the blue E-Kit sat on the counter to the left of the entrance door was unsecured with a note in between the handles which read Stop!! New E-Kit instructions. For all medications taken from the E-kit on the inventory sheet, fill out the bottom…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-11-17 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility identified a census of 18 residents. The facility had one main kitchen and one main dining room. Based on observation, interview, and record review, the facility failed to ensure that the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). Findings included:- On 09/22/25 at 08:37 AM, during the initial tour of the facility kitchen, Dietary BB stated that she was currently taking the classes to become certified but had not taken her test yet. Dietary BB further stated that the registered dietician came to the facility twice a month to review the residents' diets and address any weight loss.On 09/23/25 at 09:18 AM, Administrative Staff A stated that Dietary BB would soon be taking her test to become a certified dietary manager.The facility lacked a policy for Certified Dietary Manager as requested on 09/24/25.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 18 residents. The sample included eight residents, with one reviewed for hospitalization and one reviewed for discharge. Based on observation, interviews and record review, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) and failed to provide one resident, Resident (R) 20, with written information regarding the facility's bed hold policy when they were transferred to the hospital. The facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) for R22.Findings included: - The Electronic Medical Record (EMR) for R20 documented diagnoses of fracture of the part of the neck of the femur (broken thigh bone), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 18 residents. The sample included eight residents, with two residents reviewed for activities of daily living (ADL) care. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 18 had a functional pair of glasses needed for her impaired vision. Findings included:- R18's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN- elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), and a history of falling.R18's Annual Minimum Data Set (MDS) dated [DATE] documented she had adequate vision with glasses or other visual appliances and required corrective lenses. R18 had both short and long-term memory problems. R18 had moderately impaired cognitive skills for daily decision making. R18 was dependent on staff for her ADLs. R18 required the use of a wheelchair for mobility that staff propelled. R18's Functional Care Area Assessment (CAA) dated 02/10/25 documented she…

    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 before2025-11-17 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 18 residents. The sample included eight residents, with six reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to obtain blood pressure parameters from the physician for one resident, Resident (R) 1, who received medication to treat hypertension (high blood pressure). Findings included:- The Electronic Medical Record (EMR) for R1 documented diagnoses of hypertension, occlusion and stenosis of the right carotid artery (narrowing and blockage of one of the main blood vessels that run up the right side of the neck), and occlusion and stenosis of the right posterior cerebral artery (narrowing and blockage of the artery of the right side of the brain).The admission Minimum Data Set (MDS) dated [DATE] documented R1 had intact cognition. R1 was independent with activities of daily living and did not ambulate. The MDS further documented R1 received antidepressant (a class of medication that calms and relaxes people), anticoagulant…

    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 · D2025-11-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 18 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to date Resident (R) 6's Insulin Aspart (rapid acting) insulin (a hormone that lowers the level of glucose in the blood) pen (a device for giving insulin shots).Findings included:- On 09/22/25 at 03:45 PM, observation revealed in the medication cart, R6's Aspart insulin pen was undated when it was opened.On 09/22/25 at 03:45 PM, Licensed Nurse (LN) G verified R6's insulin pen had been used and was undated to indicate when it was opened. LN G stated staff should date the insulin pen when they open it. LN G discarded the pen in a sharps container (a puncture-resistant, rigid plastic receptacle designed to safely collect and dispose of sharp medical objects like needles, syringes, and scalpels, preventing injuries and the spread of infection).On 09/24/25 at 12:21 PM, Administrative Nurse D stated she expected staff to date an insulin pen when they opened it with the expiration date and opened date.The facility did not provide a policy…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-28 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and activities of daily living (ADL). Based on record review, observation, and interview, the facility failed to provide sufficient nurse staffing with the appropriate skill sets and competencies to treat Resident (R) 2, R3, R4, R5, and R7 with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life to maintain the highest practicable physical, mental, and psychosocial wellbeing. (Refer to F677) Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were…

    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 · E2025-04-28 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with the resident's right to a dignified existence by ensuring the residents were well groomed, clean, and dressed appropriately for the day. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for impaired dignity and psychosocial impairment. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-28 · 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

    The facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with appropriate ADL care for each resident to maintain a dignified existence and quality of life to maintain the highest practicable physical, mental, and psychosocial wellbeing. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for an undignified existence and a decline in their mental and psychosocial well-being. (Refer to F725) Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt,…

    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
Show the remaining 19 citations
  • Potential for harm · E2025-04-28 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with a resident-centered activities program that incorporated the resident's interests, hobbies, and cultural preferences to maintain or improve the resident's physical, mental, and psychosocial well-being. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for decline in meaningful interaction, meaningful activities, and psychosocial well-being. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder (category of mental health problems, feelings of sadness,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 32 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 was free from abuse when R2 touched R1 in a sexually inappropriate manner. R1, who was severely cognitively impaired, was unable to consent. This deficient practice placed R1 at risk for continued abuse and impaired psychosocial well-being. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated 10/29/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The MDS documented R1 required substantial assistance with bed mobility and was totally dependent on staff for transfer, bathing, toileting, dressing, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-11-30 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full time certified dietary manager for the 32 residents who resided in the facility and received meals form the facility kitchen. This placed the residents at risk for impaired nutrition. Findings included: - On 11/28/23 at 10:35 AM, review of the noon meal consisted of Salisbury steak, tomato soup, grilled cheese sandwich, and cinnamon apples. On 11/28/23 at 10:35AM, observation revealed Dietary Staff BB was in the kitchen and oversaw the preparation of the noon meal. On 11/28/23 at 10:35 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had started the classes but had not completed them. On 11/28/23 at 4:00 AM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. The facility's Organizational Structure -Food and Nutrition Services Policy, revised 12/18/22, documented the person who has overall responsibility for food and nutrition services…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 32 residents. The facility had one kitchen. Based on observation, record review, and interview, the facility failed to prepare food in accordance with professional standards for food service safety when staff failed to check temperatures of food items prior to serving and failed to ensure clean and sanitary refrigerators and food preparation areas. This placed the residents at risk for foodborne illness. Findings included: - On 11/27/23 at 12:35 PM, observation of the kitchen revealed the white refrigerator's bottom two shelves had numerous different-sized yellow, dried liquid stains and the freezer had numerous undated four-ounce (oz) health shakes. On 11/27/23 at 1:00 PM, observation revealed the white refrigerator/ freezer, located in the activity room on Angle Lane, had numerous undated four oz health shakes and the bottom two shelves had numerous, different-sized red, dried, food and liquid stains. On 11/28/23 at 10:30 AM, observation during follow up to the kitchen revealed an unlabeled, undated, flour and sugar container. On 11/28/23 at 12:30PM,…

    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 · Dcited before2023-11-30 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R) 16's bruises of unknown origin on her left arm and left breast area. This deficient practice placed the resident at risk for unidentified and ongoing abuse and/or mistreatment. Findings included: - R16's Electronic Medical Record (EMR) documented diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), difficulty walking, lack of coordination, and healing of left neck femur fracture (hip fracture). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R16 had a Brief Interview for Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS further documented R16 required total assist with bed mobility and transfers; R16 used a wheelchair. The Care Area Assessment Summary (CAA) dated 09/17/23, documented R16 had memory loss and was unable 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0641 — isolated
    Ensure 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 had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to assess one of 12 sampled residents, Resident (R)12's cognition on the Minimum Data Set (MDS) assessment. This placed the resident at risk for an inaccurate care plan and unmet care needs. Findings included: - R12's Electronic Medical Record (EMR) documented R12 had diagnoses of hypertension (elevated blood pressure), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R12's comprehensive admission Minimum Data Set(MDS), dated [DATE] lacked documentation regarding R12's cognition. The MDS documented R12 was independent with activities of daily living (ADLs). R12's Care Plan, revised 10/03/23, documented R12 was independent with ADLs. The plan documented R12 saw a psychologist (expert in the mind and behavior, who…

    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 before2023-11-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    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 The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 21 appropriate activities of daily living (ADL) care, which included incontinence care, for R21 placing the resident at risk for poor hygiene and impaired quality of life. Findings included: - R21's Electronic Medical Record (EMR) documented diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), contracture of left shoulder and left wrist (abnormal permanent fixation of a joint or muscle) and 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). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R21 had a Brief Interview of Mental Status (BIMS) score of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 21 the necessary care and services for positioning when in the wheelchair, or assessment and care of R21's skin. This deficient practice placed the resident at risk for discomfort and potential skin breakdown. Findings included: - R21's Electronic Medical Record (EMR) documented diagnosis of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hemiplegia (paralysis of one side of the body),hemiparesis (muscular weakness of one half of the body), contracture of left shoulder and left wrist (abnormal permanent fixation of a joint or muscle) and 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). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R21 had a Brief Interview…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    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 had a census of 32 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing for the two residents' pureed diets. This placed the residents at risk for impaired nutrition. Findings included: - On 11/28/23 at 10:35 AM, Dietary Staff (DS) CC, with DS BB overlooking, stated the facility had two residents who received pureed diets. DS CC placed two Salisbury steaks into a blender container, blended, then poured unmeasured hot water into the blender and blended to the consistency of mashed potatoes. DS BB placed the pureed Salisbury steak into a container and placed on the steam table. DS BB stated one of the resident's family members brought in some macaroni and cheese. DS CC placed the macaroni and cheese container into the microwave on high for one minute, checked the temperature (149 degrees Fahrenheit [F.]) and then placed it into a blender container. DS CC blended, then added 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 · Dcited before2023-11-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 12 residents with one reviewed for bladder and bowel incontinence. Based on observation, record review and interview the facility staff failed to follow acceptable infection control practices when staff failed to change gloves and perform adequate hand hygiene when providing Resident (R)23 incontinent cares. This placed the resident at increased risk for infection. Findings included: - R23's Electronic Medical Record (EMR) documented R23 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and hypertension (elevated blood pressure). R23's Quarterly Minimum Data Set (MDS), dated [DATE], documented R23 had short- and long-term memory problems, and modified independent cognitive skills for daily decision making. The MDS documented R23 required extensive staff assistance with dressing and personal hygiene. R23 was frequently incontinent with urine, and occasionally incontinent of bowel. R23's 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-14 · 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 The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to submit a completed investigation to the State Agency (SA) within the required five days for Resident (R) 17 for whom the facility reported an injury of unknown origin. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R17 recorded diagnoses of malignant neoplasm of transverse colon (colon cancer), acute kidney failure (when kidneys suddenly become unable to filter waste products from the blood), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had moderately impaired…

    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 before2022-07-14 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to investigate an injury and fall for one resident, Resident (R) 17, who had a fracture of her pubic ramus (pelvis bone). This placed the R17 at risk for further injury and unidentified abuse and mistreatment. Findings included: - The Electronic Medical Record (EMR) for R17 recorded diagnoses of malignant neoplasm of transverse colon (colon cancer), acute kidney failure (when kidneys suddenly become unable to filter waste products from the blood), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had moderately impaired cognition and required limited assistance of one staff 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-14 · 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 had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for hypertension (high blood pressure) with signs and symptoms of side effects from the antihypertensive medication. This placed the resident at risk for physical decline and complications related to high blood pressure. The facility further failed to develop a comprehensive care plan which addressed the risk for pressure injuries and interventions and treaments related to a recurring pressure wounds for R7. This placed the resident at risk for delayed healing, recurring wound and uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2 (when the body…

    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 · D2022-07-14 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 13 residents, with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interview, the facility failed to revise the comprehensive care plan for Resident (R)8 to include interventions to prevent pressure injuries to R8's heels and failed to revise to add treatments once a pressure injury developed on R8's left heel. This placed the resident at risk for delayed healing related to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) documented R8 had diagnoses of hypertension (high blood pressure), atrial fibrillation (an irregular heartbeat), and lymphocytic leukemia (a type of cancer of the blood and bone). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 required extensive assistance of one staff for bed mobility,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 13 residents with one resident reviewed for quality of care. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 184's skin condition including wound size and effectiveness of treatment which placed R184 at risk for delayed healing and treatment. Findings included; -The Medical Diagnosis section within R184's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (elevated blood pressure ) and atherosclerotic (a progressive hardening of the vessels supplying blood to the heart) heart disease. The admission Minimum Data Set (MDS), dated [DATE], documented R184 had moderately impaired cognition without behaviors, required supervision and set up assistance with…

    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 · D2022-07-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 13 residents with two reviewed for catheter (tube placed into the bladder to drain urine) related urinary tract infection (UTI). Based on observation, record review and interview the facility failed to prevent recurrent UTI for Resident (R)31, who had an indwelling catheter which placed the resident at risk of further infections. Findings included: - The Medical Diagnoses section with R31's Electronic Medical Record (EMR) included diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction ) stage four (sore that extend below into deep tissue, including muscle, tendon and ligaments) of the right buttock and sacral region (large triangular bone between the two hip bones), pressure ulcer stage two (sore through top layer of skin)…

    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 · D2022-07-14 · 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 The facility had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report multiple episodes of Norvasc medication not administered when the resident's blood pressure was out of parameters for Resident (R) 2. This placed R2 at risk for physical decline and complications related to high blood pressure. - The Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2's had long and short- term memory problems and required extensive assistance of two staff for bed mobility, transfers, dressing,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to administer Norvasc (a medication that treats high blood pressure) when blood pressures were out of parameters for one of five sampled residents, Resident (R) 2. This placed R2 at risk for physical decline and complications related to high blood pressure. - The Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2's had long and short- term memory problems and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to maintain the catheter (tube inserted directly into the bladder to drain urine) drainage bag for Resident (R)31, who had an indwelling catheter and a history of urinary tract infections (UTI) which placed the resident at risk of bacterial contamination and further infections. Findings included: - The Medical Diagnoses section with R31's Electronic Medical Record (EMR) included diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction ) stage four (sore that extend below into deep tissue, including muscle, tendon and ligaments) of the right buttock and sacral region (large triangular bone between the two hip bones), pressure ulcer stage 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.

    Infection Control 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

$20,207 in federal fines across 1 penalty.

  • $20,207 — penalty dated 2023-09-11

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 GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.0-1.0 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 2 of 52.8-0.8 vs chain
The other 91 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Edgebrook Care CenterEdgerton, MN 1 of 5Good Samaritan - IndianolaIndianola, IA 1 of 5Good Samaritan - Red OakRed Oak, IA 1 of 5Good Samaritan Society - AtkinsonAtkinson, NE 1 of 5Good Samaritan Society - BlackduckBlackduck, MN 1 of 5Good Samaritan Society - Grand Island VillageGrand Island, NE 1 of 5Good Samaritan Society - LakotaLakota, ND 1 of 5Good Samaritan Society - Mary Jane BrownLuverne, MN 1 of 5Good Samaritan Society - St Luke's VillageKearney, NE 1 of 5Good Samaritan Society - WindomWindom, MN 1 of 5Good Samaritan Society De SmetDe Smet, SD 1 of 5Good Samaritan Society MillerMiller, SD 1 of 5Salem Lutheran HomeElk Horn, IA 1 of 5Souris Valley Care CenterVelva, ND 1 of 5St Vincent's - A Prospera CommunityBismarck, ND 1 of 5Sunset Drive - a Prospera CommunityMandan, ND 2 of 5Good Samaritan - AtwoodAtwood, KS 2 of 5Good Samaritan - EsthervilleEstherville, IA 2 of 5Good Samaritan - MansonManson, IA 2 of 5Good Samaritan - OttumwaOttumwa, IA 2 of 5Good Samaritan - WaukonWaukon, IA 2 of 5Good Samaritan Society - BottineauBottineau, ND 2 of 5Good Samaritan Society - Hastings VillageHastings, NE 2 of 5Good Samaritan Society - OakesOakes, ND 2 of 5Good Samaritan Society - Park RiverPark River, ND 2 of 5Good Samaritan Society - Specialty Care CommunityRobbinsdale, MN 2 of 5Good Samaritan Society - St John'sKearney, NE 2 of 5Good Samaritan Society - St Martin VillageRapid City, SD 2 of 5Good Samaritan Society - SuperiorSuperior, NE 2 of 5Good Samaritan Society - Waconia And Westview AcreWaconia, MN 2 of 5Good Samaritan Society CantonCanton, SD 2 of 5Good Samaritan Society Luther ManorSioux Falls, SD 2 of 5Good Samaritan Society New UnderwoodNew Underwood, SD 2 of 5Good Samaritan Society Sioux Falls CenterSioux Falls, SD 2 of 5Good Samaritan Society Sioux Falls VillageSioux Falls, SD 2 of 5Good Samaritan-LiberalLiberal, KS 2 of 5The Good Samaritan Society-Kissimmee VillageKissimmee, FL 3 of 5Good Samaritan - AlgonaAlgona, IA 3 of 5Good Samaritan - DavenportDavenport, IA 3 of 5Good Samaritan - HolsteinHolstein, IA

Showing 40 of 91; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
SANFORDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2019
THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETYOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 01/01/2019
BROWN, GEORGEIndividualCORPORATE DIRECTORsince 01/01/2025
DYKHOUSE, DANAIndividualCORPORATE DIRECTORsince 05/30/2024
ENGBRECHT, WESLEYIndividualCORPORATE DIRECTORsince 05/30/2024
GASSEN, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/30/2024
GULSVIG, NEILIndividualCORPORATE DIRECTORsince 05/30/2024
HERSETH SANDLIN, STEPHANIEIndividualCORPORATE DIRECTORsince 05/30/2024
LUNDEEN, MARKIndividualCORPORATE DIRECTORsince 05/30/2024
MCCAUSLAND, MAUREENIndividualCORPORATE DIRECTORsince 01/01/2025
MOLBERT, LAURISIndividualCORPORATE DIRECTORsince 05/30/2024
NORTH, ANDREWIndividualCORPORATE DIRECTORsince 05/30/2024
SCHIEFFER, KEVINIndividualCORPORATE DIRECTORsince 01/01/2025
SHULKIN, DAVIDIndividualCORPORATE DIRECTORsince 05/30/2024
TEIKEN, BRENTIndividualCORPORATE DIRECTORsince 05/30/2024
VENTLING-HERRMANN, MARNIEIndividualCORPORATE DIRECTORsince 05/30/2024
WENZEL, THOMASIndividualCORPORATE DIRECTORsince 01/01/2025
FLUIT, JOELIndividualCORPORATE OFFICERsince 10/01/2022
MIDDLETON, AIMEEIndividualCORPORATE OFFICERsince 01/27/2022
OLSON, NICHOLASIndividualCORPORATE OFFICERsince 04/08/2024
SCHEMA, NATHANIndividualCORPORATE OFFICERsince 01/01/2022
BARTRUFF, CRAIGIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/13/2018
KLINEDINST, TAMIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/15/2023
MORRISON, TONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019

CMS files one row per role, so the 28 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$3.3M
Net patient revenuemost recent cost report
-4.1%
Operating marginrevenue minus expenses
$554K
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 2%Other / private 46%

This home reported $554K paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$287per resident / day
operating cost
$8,729per month
≈ monthly operating cost
$276per day
avg. revenue, all payers

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

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175356. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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