Rock Creek Of Ottawa
1100 W 15th Street, Ottawa, KS 66067 · For profit - Corporation · 75 certified beds · (785) 242-5399 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,278 in federal fines (most recent 2026-01-27)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (58%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.8% | 17.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 4.9% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.5% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 45.6% | 6.5% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.4% | 4.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 7.9% | 16.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.0% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 30.4% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.4% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.7% | 73.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.6% | 22.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.4% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.30 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.29 | 2.13 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 190 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 130 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.6%CMS range 55.0–67.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.7–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 73.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 64.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 77.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.2–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 75 beds and averages 72.1 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.22 hrs/resident/day on weekends vs 3.70 on weekdays — 13% thinner on weekends. RN hours go from 0.66 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2026-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility documented a census of 69 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure an environment free from accident hazards for Resident (R) 1, who required staff assistance and a mechanical lift for safe transfers. As a result, R1 sustained a humerus (upper arm bone) fracture of her left arm. Findings included:- The Electronic Medical Record (EMR) for R1 documented diagnoses of morbid (severe) obesity (BMI-Body Mass Index of 40 or greater, or a BMI of 35 or greater with one or more serious health conditions), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R1 had an Annual Minimum Data Set (MDS), dated 02/10/25, which documented a Brief Interview for Mental Status (BIMS) of seven, which indicated severe cognitive impairment. The assessment also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 72 residents. The facility had one main kitchen and one dining room. Based on observation, record review, and interview, the facility failed to ensure food was properly stored. The facility failed to ensure that the freezer was in proper working condition. The facility failed to ensure freezer temperatures remained at the required temperatures. The facility failed to ensure food temperatures were logged to ensure appropriate temperatures were reached before serving. Findings included: - Upon entry to the kitchen on 01/28/245 at 07:20 AM, it was observed and noted: In the server refrigerator, a half-gallon container of cottage cheese was over half empty and lacked an open date on the outside of the container. A gallon container of milk had been opened but lacked an open date. The bread rack had three opened loaves of bread and buns that were not in sealed, dated, or labeled bags. The dry storage room had a bag of macaroni and a bag of pasta shells that had been opened but were not in a sealed, dated, or labeled bag. The walk-in freezer had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-30 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 identified a census of 72 residents. The sample included 19 residents, four medication carts, and two medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in two of the four medication carts. The facility also failed to label medication in one of the two medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - During the initial tour on 01/28/25 at 07:10 AM, a medication cart on the [NAME] hallway was unlocked and unattended in the hallway. On 01/28/25 at 07:19 AM, the second medication cart on the [NAME] hallway was unlocked and unattended. The medication cart contained two opened, undated insulin (a hormone that lowers the level of glucose in the blood) pens. On 01/28/25 at 07:12 AM, Certified Medication Aide (CMA) R stated she thought she had locked the medication cart when she had walked away from the cart. CMA R stated the medication cart should never be left unlocked when not in use. On 01/28/25 at 07:23 AM, Licensed Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 72 residents. The sample included 19 residents, with Resident (R)28 reviewed for dignity. Based on observation, record review, and interview, the facility failed to ensure staff respected R28's privacy and dignity while in bed. This deficient practice placed R28 at risk of decreased self-esteem and decreased self-worth. Findings included: - R28's Electronic Medical Record (EMR) documented diagnoses of chronic respiratory failure (a condition where your blood does not have enough oxygen), dementia (a progressive mental disorder characterized by failing memory and confusion), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R28's admission Minimum Data Set (MDS) dated 07/21/24 documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R28 had an impairment of his lower extremity on one side. R28 used a wheelchair to assist with mobility. R28 required substantial assistance to total dependence on staff for his functional abilities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 72 residents. The sample included 19 residents, with five reviewed for accommodation of needs related to assistive devices. Based on observation, record review, and interview, the facility failed to utilize and ensure the appropriate use of foot pedals during wheelchair transports for Resident (R) 65 and R51. The facility additionally failed to ensure that R43, R24, and R8 call lights remained within their reach. This deficient practice placed the resident at risk for preventable accidents and injuries. Findings Included: - A review of R65's (severely cognitively impaired resident) EMR under Progress Notes revealed a Fall Committee Note completed on 07/22/24. The note indicated R65 had a minor injury fall on 07/19/24. The note revealed that R65 fell out of his wheelchair while being pushed in the hallway without foot pedals. The note revealed that R95 became fatigued while he attempted to hold his legs up. The note revealed he suffered a skin tear on his left elbow, left wrist, left hand, and below his left eye. The note revealed all staff were educated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 72 residents. The sample included 19 residents, with four residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide written notification of transfer to Resident (R) 28 and his representative for his facility-initiated transfers. This deficient practice placed R28 at risk for uninformed care choices. Findings included: - R28's Electronic Medical Record (EMR) documented diagnoses of chronic respiratory failure (a condition where your blood does not have enough oxygen), dementia (a progressive mental disorder characterized by failing memory and confusion), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R28's Discharge Minimum Data Set (MDS) dated 03/15/24 documented an admission to the facility on [DATE]. The MDS documented an unplanned discharge to an acute hospital with a return anticipated. R28's Discharge MDS dated 03/22/24 documented 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.
- Potential for harm · Dcited before2025-01-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 72 residents. The sample included 19 residents, with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, because of pressure or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 19's low air-loss mattress was set to the appropriate weight settings per her current weight. The facility additionally failed to ensure R34's Wheelchair had a pressure-reducing cushion in place per her care-planned interventions. This deficient practice placed both residents at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) noted diagnoses of muscle weakness, cognitive-communication disorder, and deep surgical incision with wound-vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 72 residents. The sample included 19 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 24 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R24 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of contracture of left hand, hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), 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 Significant Change Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 72 residents. The sample included 19 residents, with two residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure an electrical furnace closet out of reach of 30 cognitively impaired/independently mobile residents. The facility additionally failed to ensure Resident (R)19's care-planned fall interventions were in place. This deficient practice placed the identified residents at risk for preventable injuries and accidents. Findings Included: - On 01/28/25 at 07:05 AM, an initial walkthrough of the facility was completed. Upon inspection of the [NAME] Hall, it revealed a furnace closet next to the resident rooms. The closet double doors were locked but easily pulled open due to damage to the door's frame. The closet contained numerous electrical boxes that contained the warning, high voltage - danger of electric shock. On 01/28/25 at 07:06 AM, Administrative Staff B verified the door would not secure and stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 72 residents. The sample included 19 residents, with two residents reviewed for bowel/bladder incontinence, a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), and urinary tract infection (UTI - an infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 67 with an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) when the facility failed to prevent his catheter drainage bag from resting on the floor. This deficient practice placed R67 at risk for catheter-related complications. Findings included: - R67's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate, which can lead to interference with urine flow, urinary frequency, and urinary tract…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 72 residents. The sample included 19 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 28 had his physician-ordered supplemental oxygen on as ordered. The facility failed to ensure R28's nasal cannula (NC - a thin hollow tube that assists in providing supplemental oxygen) was appropriately stored when not used. This deficient practice placed R28 at risk of respiratory complications and possible infection. Findings included: - R28's Electronic Medical Record (EMR) documented diagnoses of chronic respiratory failure (a condition where your blood does not have enough oxygen), dementia (a progressive mental disorder characterized by failing memory and confusion), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R28's admission Minimum Data Set (MDS) dated 07/21/24 documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R28 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2025-01-30 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 72 residents. The sample included 19, with one reviewed for competent staffing. Based on interviews and record reviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to order Resident (R) 33's physician-ordered eyedrops. This deficient practice placed R33 at risk for impaired quality of care. Findings included: - The Medical Diagnosis section within R33's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, cognitive-communication deficit, 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). R33's admission Minimum Data Set (MDS) completed 10/18/24 noted a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The MDS indicated she required partial to moderate assistance from staff to complete transfers, toileting, bathing, dressing, bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 72 residents. The sample included 19 residents, with one reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion) care. Based on interviews, record review, and observations, the facility failed to provide dementia-related behavioral services for Resident (R) 65 to promote his highest practicable level of well-being, resulting in numerous non-injury falls. This deficient practice placed R65 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R65's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dysphagia (difficulty swallowing), muscle weakness, cognitive-communication disorder, and a history of falls. R65's Quarterly Minimum Data Set (MDS) completed 10/18/24 revealed a Brief Interview for Mental Status (BIMS) score of six that indicated severe cognitive impairment. The MDS revealed no wandering, rejection of care, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 72 residents. The sample included 19 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure physician parameters were followed for a hypertensive medication (class of medication used to treat hypertension (high blood pressure) for Resident (R) 2. This deficient practice had the potential of unnecessary medication administration, thus leading to possible harmful side effects. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and hypertension. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The Quarterly MDS dated 12/16/24 documented a BIMS score of 14, which indicated intact cognition. R2's Psychotropic Drug Use Care Area…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 72 residents. The sample included 19 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview. The facility failed to ensure Resident (R) 8 had an adequate Centers for Medicare and Medicaid (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. This deficient practice placed the resident at risk for unnecessary medication administration and related complications. Findings included: - The Electronic Medical Record (EMR) for R8 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), and hypertension (elevated blood pressure). R8's admission Minimum Data Set (MDS) dated 01/16/25 documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated severely impaired cognition. R8 required supervision…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 72 residents. The sample included 19 residents. Based on record review, observations, and interviews, the facility additionally failed to follow sanitary infection control practices related to oxygen equipment storage and Foley catheter care. These deficient practices placed the residents at risk for infectious diseases. Findings Included: - On 01/29/25 at 03:36 PM, Resident (R) 67 sat in his recliner in his room. R67's urinary catheter collection bag rested directly on the floor. Amber-colored urine was visible in his collection bag. On 01/28/25 at 10:40 AM, R28's supplemental oxygen nasal cannula was found resting on top of his bed. No plastic storage bag was observed in his room. On 01/30/25 at 12:04 PM, Certified Nurse's Aide (CNA) M stated all oxygen tubing and equipment should be stored inside clean plastic bags when not in use. She stated the tubing and cannulas should be replaced when contaminated. She stated the masks should be wiped down. She stated the urine collection bag was to be placed below the level of the bladder and never touch…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 72 residents with three selected for review for falls. Based on observation, interview and record review, the facility failed to ensure staff provided fall intervention as care planned for one Resident (R)2, of the three residents reviewed. Findings included: - Review of Resident (R)2's medical record, revealed diagnoses included lymphedema (swelling caused by accumulation of lymph), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with neuropathy (damage of the nerves outside of the brain and spinal cord usually the hands and feet that cause weakness, numbness and pain) and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS) dated [DATE]. assessed the resident with a brief interview for mental status score (BIMS) of 15 which indicated normal cognitive function. The resident required supervision of activities of daily living (ADL) with unsteady balance and required stabilization 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.
- Potential for harm · Fcited before2023-03-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 72 residents. Based on observation, interview and record review, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility, as exhibited by the failure to store and label food in the refrigerator, maintain a clean refrigerator for the resident's foods and failure to utilize pasteurized eggs (a process which kills harmful bacteria) for resident's who request soft-cooked eggs for breakfast. Findings included: - During an environmental tour on 03/28/23 at 07:36 AM, the following areas of concern were noted: 1. Dietary Staff BB failed to utilize pasteurized eggs when she cooked and served six to eight soft-cooked eggs to residents. 2. The reach in refrigerator contained an open container of Ranch salad dressing which lacked an open date. 3. The reach in refrigerator contained an open container of Mayonnaise which lacked an open date. 4. The reach in refrigerator contained a large amount of food debris on the bottom shelf. 5. The inside of the microwave in the kitchen area had a large amount of splattered,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-29 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 72 residents. Based on observation, interview, and record review the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)64, regarding inaccurate discharge location. Findings included: - Review of Resident (R)64's medical record revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The entry Minimum Data Set (MDS), dated [DATE], documented the resident admitted from an acute hospital. The care plan, dated 02/06/23, instructed the staff the resident intended to return home following his stay at the facility. The discharge MDS, dated 02/13/23, documented the resident discharged from the facility to an acute hospital. On 03/29/23 at 08:51 AM, Administrative Nurse E stated the resident discharged from the facility to home on [DATE]. The discharge MDS, dated [DATE], was inaccurate as it documented the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-29 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 reported a census of 72 residents with 20 selected for review including one reviewed for restorative nursing contracture management (abnormal permanent fixation of a joint). Based on observation, interview, and record review, the facility failed to provide restorative services of contracture management services for the one sampled Resident (R)31. Findings included: - The Medical Diagnosis tab for R31 included diagnosis of Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one side of the body) following cerebral infarction (stroke- damage to tissues in the brain due to a loss of oxygen to the area), and contracture of the left hand. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R31 with a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. She had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 72 residents with 20 selected for review. Based on observation, interview, and record review, the facility failed to assess, monitor, and implement interventions to prevent further accidents/injuries for two residents, Resident (R)42 and R21, with bruises, and failed to ensure immediate appropriate interventions were implemented for R9 following falls to prevent further falls/injury. Findings included: - The Medical Diagnosis tab for R9 included diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), repeated falls, history of falling, cognitive communication deficit, muscle weakness, dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and urge incontinence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 72 residents. Based on observation interview and record review, the facility failed to maintain an effective infection control program with the failure to change out nasal cannula tubing per physician order for Resident (R)40, failed to administer eye drops in a sanitary manner for R4, and failed to dispose of a used contaminated needle properly. These practices failed to follow infection control standards to reduce the risk of causing or spreading infections or exposure to a blood borne pathogen (infectious microorganism in human blood that can cause disease in humans). Findings included: - The Medical Diagnosis tab for R40 included diagnoses of pneumonia (inflammation of the lungs), obstructive sleep apnea (disorder of sleep characterized by periods without respirations), and Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) dated [DATE] assessed R40 with a Brief Interview of Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2021-08-09 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 61 residents. Based on interview and record review the facility failed to use the services of a registered nurse for eight consecutive hours a day, on four days in a three-month period between 05/01/21 to 07/31/21. Findings Included: - Review of the facility schedules, from 05/01/21 to 08/09/21, daily staff postings, and hours worked summaries revealed the following: 1. A facility staffing schedule titled When to Work.Com dated 05/08/21, which scheduled a registered nurse on the 02:00PM to 10:00 PM shift. A facility staff posting sheet titled Nurse Staff information dated 05/08/21 documented one registered nurse for the 02:00PM to 10:00 PM shift. A Labor Hours Summary Report dated 05/08/21 documented 4.88 registered nurse hours. 2. A facility staffing schedule titled When to Work.Com dated 05/15/21 revealed no scheduled registered nurse. A facility staff posting sheet titled Nurse Staff information dated 05/15/21 documented no registered nurse on duty. A Labor Hours Summary Report dated 05/15/21, documented no registered nurse hours. 3. A facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-09 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - Review of Resident (R)49's Physician Order Sheet, dated 07/30/21, revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion,) major depressive disorder (major mood disorder,) and macular degeneration (progressive deterioration of the retina.) The Annual Minimum Data Set (MDS) dated 12/26/2020 assessed the resident had severe cognitive impairment, required extensive assistance for activities of daily living (ADL), and had no impairment in range of motion in upper or lower extremities. The Activity of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment [CAA] did not trigger. The Care Plan reviewed 07/02/21 instructed staff the resident required the assistance of one staff for bathing, personal hygiene and dressing. The care plan instructed staff to allow enough time for dressing and staff would turn on music in her room to help calm her down when restless. Observation on 08/03/21 at 01:31 PM revealed the resident seated in her wheelchair at the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-08-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 61 residents with 17 selected for review. Based on observation, interview, and record review the facility failed to review and revise the care plan for Residents, (R)49 for refusal of nail care. Findings included: - Review of R 49's Physician Order Sheet dated 07/30/21, revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion,) major depressive disorder (major mood disorder,) and macular degeneration (progressive deterioration of the retina.) The Annual Minimum Data Set (MDS) dated 12/26/20 assessed the resident had severe cognitive impairment, required extensive assistance for activities of daily living (ADL), and had no impairment in range of motion in upper or lower extremities. The Activity of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment [CAA] did not trigger. The Care Plan reviewed 07/02/21 instructed staff the resident required the assistance of one staff for bathing, personal hygiene, and dressing. The care plan instructed staff to allow enough time for 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.
- Potential for harm · D2021-08-09 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 61 residents with 17 residents sampled, including four residents reviewed for activities. Based on interview, record review, and observation, the facility failed to provide an ongoing program of individualized activities for Resident (R)12. Findings included: - Review of Resident (R)12's electronic medical record (EMR), under the Med Diag[nosis] tab, included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating he had moderately impaired cognition. It was very important for the resident to be able to listen to music he liked and he was the primary respondent for the activity preferences. The Activity Care Area Assessment (CAA), dated 09/16/20, did not trigger. The Activities Care Plan, dated 07/25/21, instructed staff that the resident enjoyed listening to country/western music, walking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-08-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 61 residents. The sample contained 17 residents with one resident reviewed for non-pressure related skin issues. Based on observation, interview, and record, review the facility failed to implement care planned skin protection interventions of pressure reducing boots on both feet and repositioning every two to three hours for one resident, Resident (R) 29. Findings included: - The signed Physician Order Sheet (POS), dated 07/29/21, documented R29's diagnoses included: peripheral vascular disease (abnormal condition affecting the blood vessels), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). An Annual Minimum Data Set (MDS) dated [DATE] documented R29 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. He required extensive assistance with bed mobility and transfer.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-08-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 61 residents with 17 selected for review, which included two residents selected for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure sanitary dressing changes for one Resident (R)8 of the two residents reviewed. Findings included: - Review of R8's Physician Order Sheet, dated 07/27/21, revealed diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, mask-like faces, shuffling gait, muscle rigidity and weakness,) and congestive heart failure (a condition with low heart output and the body becomes congested with fluid). The Quarterly Minimum Data Set (MDS), dated 04/29/21, assessed the resident had moderate cognitive impairment and required extensive assistance for transfer and bed mobility. The resident was at risk for pressure ulcers, had preventive measures in place, and this MDS indicated no current pressure ulcer. The Pressure Ulcer Care Area Assessment (CAA), assessed the resident was at risk for pressure ulcers and had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,278 in federal fines across 1 penalty.
- $8,278 — penalty dated 2026-01-27
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 THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; 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 / manager | Type | Role | Since |
|---|---|---|---|
| BOHRER, TRACY | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2018 |
| BUNKER, DEREK | Individual | CORPORATE OFFICER | since 07/11/2018 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 07/11/2018 |
| GUSCHL, JAMES | Individual | CORPORATE OFFICER | since 11/01/2018 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 10% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175332. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, 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.