Medicalodges Paola
501 Assembly Lane, Paola, KS 66071 · For profit - Corporation · 70 certified beds · (913) 294-3345 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0609) — most recent Sep 2024
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- inspectors recorded 2 serious findings 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $78,225 in federal fines (most recent 2024-09-04)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 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 improved from 1 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 | 25.5% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.1% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.4% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.0% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 22.4% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 39.5% | 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 | 0.0% | 4.4% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 6.9% | 22.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 100.0% | 18.1% | 17.1% | check this† — see note marked dagger below the table |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
† 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.
Therapy staffing: this home’s payroll records show 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 52% of this home’s weekday level — it runs therapy at close to weekday levels right through 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 70 beds and averages 67.6 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 1.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.01 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 1.68 hrs/resident/day on weekends vs 1.99 on weekdays — 16% thinner on weekends. RN hours go from 0.46 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 15 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2024-09-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent the neglect of Resident (R)1, when staff did not utilize appropriate transfer equipment to safely meet the needs of R1, who displayed signs of weakness during cares. On 08/28/24 at 02:40 PM, Licensed Nurse (LN) G, Certified Nurse Aide (CNA) M, CNA N, and Certified Medication Aide (CMA) R assisted R1 to stand, with use of a gait belt that was not the appropriate size for R1. As two of the staff members attempted to pull R1's incontinence brief up, R1's legs became weak, and staff lowered R1 to the floor. During the lowering, the resident's left leg buckled underneath the resident and rotated outward, which caused a popping noise. The facility called Emergency Medical Services (EMS) to transfer R1 to the Emergency Department (ED). R1 admitted to the hospital with an obliquely oriented fracture (the bone fractured at an angle)…
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.
- Immediate jeopardy · J2024-09-04 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
The facility reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to report the elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff) of Resident (R)2 to the State Agency, as required. On 08/27/24 at 08:48 PM R2 left the facility without staff knowledge or supervision and at approximately 10:41 PM, Law Enforcement called the facility to advise them they had received calls noting that R2 was walking on the highway, entered a gas station approximately 0.9 miles from the facility. Law Enforcement advised License Nurse (LN) H that someone needed to come to their location because Law Enforcement had the R2 surrounded with their patrol cars due to his threats to Law Enforcement and the store clerk, yelling, cursing and agitation. The LN H reported she immediately drove to the gas station in her personal vehicle, without contacting Administrative Staff 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.
- Immediate jeopardy · Jcited before2024-09-04 · 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 reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to protect Resident (R) 2 from possible harm when he exited the facility unsupervised and without staff knowledge (elopement) on 08/27/24 at 08:48 PM. At approximately 10:41 PM, Law Enforcement called the facility to inform them they received calls noting R2 was walking on the highway, then entered a gas station (approximately 0.9 miles from the facility), threatened a store clerk, and wanted to buy cigarettes with postage stamps. Law Enforcement informed License Nurse (LN) H someone needed to come to their location because Law Enforcement had R2 surrounded with their patrol cars due to his threats of yelling, cursing and agitation to Law Enforcement Officers and the store clerk. LN H reported she immediately drove her personal vehicle to the gas station, without contacting Administrative Staff A or Administrative Nurse D, and returned to the facility with R2. LN H said as she drove R2 back to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2023-11-06 · 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 62 residents with 18 residents selected for review, which included two residents reviewed for elopement. Based on observation, interview, and record review the facility failed to ensure staff provided a safe and secure environment to include adequate supervision for cognitively impaired Resident (R) 44, who the facility care planned for 15-minute checks due to a history of making elopement statements. On 10/22/23 at 05:07 AM R44 left the facility and walked approximately 0.6 miles to a local grocery store (which opened at 06:00 AM). The resident was observed in the grocery store eating at the salad bar. The facility did not realize R44 was missing for four hours and 23 minutes, when local police called the facility at 09:15 AM to report they located the resident and then returned the resident to the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - Review of Resident (R)44's Physician Order Sheet, dated 10/04/23, revealed diagnoses…
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.
- Immediate jeopardy · Jcited before2023-09-21 · 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 62 residents with three selected for review for elopement. Based on observation, interview, and record review the facility failed to prevent an elopement when Resident (R)1 exited the facility grounds, unsupervised on 07/30/23 at 04:48 PM and remained outside of the facility grounds for approximately four hours. While out of the facility unsupervised, the resident walked 0.5 miles to a convenience store on a two-lane paved road. The temperature was 96 degrees Fahrenheit. While at the convenience store, the resident complained of chest pain and Emergency Medical Service (EMS) was called, and the resident was transported to the emergency room. Certified Medication Aide (CMA) R did not locate the resident at dinner time around 05:00 PM and notified Licensed Nurse (LN) H, who told CMA R to look for the resident. LN H or LN G did not know CMA R could not locate the resident and did not activate the elopement protocol. The facility did not know of R1's whereabouts until the emergency…
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 before2025-07-29 · 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 63 residents and one kitchen. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria placing them at risk of food-related illness.Findings included: - During an initial tour of the kitchen on 07/27/25 at 10:51 AM, the following areas of concern were noted:1. The hand-washing sink had a build-up of dirt and grime.2. The trash can next to the hand-washing sink had dried on food and fluid.3. Three large plastic containers holding dried milk, flour, and sugar had a build-up of dust and a sticky substance on the lids.4. Four cutting boards had deep grooves, making them unsanitizable.5. Several drawers containing cutting boards, cooking utensils, and hot pads had food debris in the bottom.6. A corner cabinet used to hold sandwich bags, plastic wrap, and plastic containers had food debris throughout.7. The fronts of several cabinet doors had a build-up of dried-on food and liquid substance.8.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-07-29 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 63 residents. Based on interview, and record review, the facility failed to ensure the mandatory 12-hours of education were completed for one Certified Nurse Aide (CNA) as required. This placed the residents at risk for decreased quality of care.Findings included:- Review of CNA N's personnel and training records revealed CNA N was hired on 01/20/20. CNA N's files lacked evidence that he had completed any of the mandatory 12 hours of education for the last 12 months.On 07/28/25 at 02:26 PM, Certified Medication Aide (CMA) S stated that required education was performed online through Relias. On 07/29/25 at 10:19 AM, Administrative Nurse D reported that staff were expected to complete mandatory online training, which included the required 12 hours of mandatory training, periodically each month.On 07/29/2025 at 10:39 AM, Administrative Staff A stated that the required and mandatory 12 hours of education had to be done; there was no excuse for it not to be completed in a 12-month period. Administrative Staff A further stated that there was a monitoring…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-29 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 63 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, and homelike environment in four of 23 resident rooms on the south hall placing the residents at risk of an uncomfortable and unhomelike environment. Findings included:- During an initial environmental tour of the south hall on 07/26/25 at 08:00 AM, the following issues were noted: 1. Resident (R)38's room had a build-up of a black substance around the base of the toilet. The wall beneath the sink had a large area that had been cut out and not repaired. 2. R13's room had areas of cove base several feet long that had separated from the wall. A build-up of a black substance had built up in the gap between the cove base and the wall. 3. R19's room had an area of cove base that had separated from the wall. A build-up of a black substance had built up in the gap between the cove base and the wall. The base of the window lacked paint in several areas. The bathroom door had multiple areas of missing paint. 4. R24's room had multiple areas…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-29 · 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
The facility identified a census of 63 residents. The sample included 17 residents including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to act upon blood pressure monitoring for Resident (R) 50 and administer a hypertensive (high blood pressure) medication per the physician orders. This placed the resident at risk for complications related to high blood pressure and ineffective medication regimen.Findings included:- R50's Electronic Health Record (EHR) revealed a diagnosis of hypertension (HTN-elevated blood pressure).R50's 06/27/25 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R50 had an active diagnosis of hypertension.R50's Care Plan dated 07/27/25 documented he had hypertension. The plan instructed staff to direct R50 to report complaints of headaches, dizziness, vision changes, chest pain, or palpitations. The plan noted R50 received Lisinopril (an antihypertensive medication) and Metoprolol (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 before2025-07-29 · 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
The facility reported a census of 63 residents. The sample included 17 residents. Based on interviews, record reviews and observation, the facility staff failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)8 and for R21 who had wounds and received wound care. This deficient practice placed the residents at increased risk for infections. Findings included:- Observed on 07/27/25 at 09:50 AM, there was no EBP personal protective equipment (PPE) or signage set-up in or around R8's room.Observed on 07/27/25 at 11:57 AM, R21 had no EBP personal protective equipment (PPE) or signage set up in or around his room.Observed on 07/28/25 at 09:00 AM, there was no EBP PPE or signage set up in or around R8's room.Observed on 07/29/25 at 08:35 AM, Licensed Nurse (LN) G opened the door after she finished R21's treatment. LN G stated the incision was closed, but there were two open areas they were debriding (medical removal of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-06 · 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 62 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for the spread of food borne bacteria. Findings included: - During an initial tour of the kitchen on 11/02/23 at 08:05 AM, the following areas of concern were noted. 1. The front of the cabinet doors of the hand-washing sink were visibly soiled. 2. The trash can by the hand-washing sink had dried-on food debris. 3. Two red rolling carts had a build-up of dirt and grime in the grooved handles. 4. One rolling cart, which held the clean silverware, had four rusty legs and wheels. 5. The two oven doors had a build-up of a sticky substance on the handles of the doors. 6. The oven doors had dried food debris covering most of the surface. 7. The stationary can opener had a dried-on, sticky food substance on the cutting blade tip. 8. Two cutting boards were heavily gouged, making the surface uncleanable. 9. The door of the walk-in refrigerator 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 · Ecited before2023-11-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 62 residents. Based on observation and interview, the facility failed to ensure a safe, sanitary, and homelike environment for the residents of the facility in the identified resident areas. Findings included: - Observation on 11/06/23 at 01:15 PM, with Maintenance staff U, revealed the following areas of concern: 1. Six resident rooms on the north hall contained an accumulation of dirt and grime in the corners of the room. 2. One resident bathroom on the north hall contained staining over the surface of the floor, accumulation of dirt and grime along the perimeter of the floor. 3. The north hall men's shower room contained floor corners with an accumulation of grime. 4. The north hall clean utility room floor contained accumulated grime and debris around the perimeter of the floor, and across the surface of the floor. 5. The resident phone room floor perimeter contained grime and black discolorations. 6. The floor near the north hall exit door contained grime and two dead bugs. (First observed 11/01/23) 7. The corners of the floor at the double…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-06 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
The resident reported a census of 62 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff in the facility kitchen areas. Findings included: - During an initial tour of the kitchen on 11/02/23 at 08:05 AM, the following areas of concern were noted. The floor throughout the kitchen and storage room had a build-up of dirt and grime around the parameters of the rooms and a heavy build-up of dirt and grime around the feet of all tables and equipment of the kitchen. On 11/06/23 at 02:01 PM, Dietary staff CC confirmed the floors of the kitchen areas needed to be kept clean at all times. The facility policy for Cleaning Rotation, dated 2011, included: The kitchen floors will be cleaned daily. The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff in the kitchen areas.
- Potential for harm · D2023-11-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 62 residents with 18 residents sampled, including one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to one Resident (R)25, by not having a dignity bag for his indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) collection bag. Findings included: - Review of Resident (R)25's electronic medical record (EMR), dated 11/01/23, documented a diagnosis of neurogenic bladder (a condition where normal bladder function was disrupted due to nerve damage). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He had an indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA),…
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 before2023-11-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 62 residents with 18 residents sampled. Based on observation, interview and record review, the facility failed to review and revise the care plan for one Resident (R)25, with the failure to include staff instructions on the use of a dignity bag in the care plan for the resident's indwelling urinary catheter collection bag. Findings included: - Review of Resident (R)25's electronic medical record (EMR), dated 11/01/23, documented a diagnosis of neurogenic bladder (a condition where normal bladder function was disrupted due to nerve damage). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He had an indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 05/15/23, documented the resident had an indwelling urinary…
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 12 citations
- Potential for harm · D2023-11-06 · 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 62 residents with 18 residents sampled. Based on observation, interview and record review, the facility failed to draw the physician ordered labs for this one dependent resident, Resident (R)57, to monitor his well-being and physical/mental health. Findings included: - The Physician Order Sheet (POS), dated 10/31/233, documented the resident had diagnoses, which included: hyperlipidemia (high levels of fat in the blood), major depressive disorder (MDD-a major mood disorder) and alcohol induced dementia (a form of dementia caused by long-term, excessive consumption of alcoholic beverages which can cause memory loss, cognitive impairment, mood changes, gait problems and hallucinations). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He received an antipsychotic (medication used to treat psychosis) and an antidepressant (medication used to treat…
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 before2023-11-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 62 residents. Based on observation and interview, the facility failed to ensure containment of biohazardous waste in a manner to prevent the spread of infection for one Resident (R)47 and failed to obtain identification of the causative organism for the resident's chronic wound. Findings included: - Observation, on 11/01/23 at 11:04 AM, revealed Licensed Nurse (LN) G provided wound vac (a device used to heal wounds by pulling drainage from the wound with pressure) care to Resident (R)47. LN G stated the resident was on contact precautions due to osteomyelitis (infection in the bone) due to the wound on the resident's right foot. Upon completion of the procedure, LN G placed the soiled dressings and used wound vac supplies in a trash can in the resident's room. The resident's room contained a large box lined with a red bag which was uncovered and contained tubing exposed out of the red bag near the room door to the hallway. Observation, on 11/02/23 at 08:48 AM, revealed the box remained full of tubing not contained within the box and the trash can…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-03-07 · 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 63 residents. Based on observation, interview, and record review the facility failed to provide sanitary food storage, preparation, and distribution for the residents of the facility. Findings included: - The initial environmental tour of the kitchen on 02/28/22 at 12:20 PM, revealed the following areas of concern: 1. The handles and the front of the convection oven contained a brown colored grime. 2. The backsplash on the grill contained a build-up of grime. 3. The outlet behind the table, where a toaster sat, contained a build-up of grime. 4. The shelf over the grill contained a thick layer of dust. 5. The kitchen cabinets contained a thick layer of grime build-up. Interview, on 02/28/22 at 12:20 PM, with Dietary Staff BB, confirmed the areas/items identified above in need of cleaning. The facility policy Sanitizing Equipment and Food Contact Surfaces, dated 2011, instructed staff to sanitize equipment and food contact surfaces utilizing the proper sanitizing solution. This policy lists a Cleaning Rotation for staff to follow. The facility failed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-03-07 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 63 residents. Based on observation, interview and record review, the facility failed to maintain floors in the kitchen and dry food storage room in a clean and sanitary manner. Findings included: - The initial environmental tour of the kitchen on 02/28/22 at 12:20 PM revealed the following areas of concern: 1. The floors all around the kitchen contained a dark colored grime build-up around the edges, near the walls. 2. The floors all around in the dry storage room contained a build-up of dirt, near the walls. Interview, on 02/28/22 at 12:20 PM, with Dietary Staff BB, confirmed the above kitchen flooring areas in need of cleaning. The facility policy Cleaning Rotation, dated 2011, instructed staff to clean the kitchen and dining room floors daily. The facility failed to maintain the floors in the kitchen and dry food storage area in a clean and sanitary manner.
- Potential for harm · Ecited before2022-03-07 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 63 residents. Based on observation and interview, the facility to provide housekeeping and maintenance services to maintain and orderly, sanitary and comfortable environment for the residents of the facility, in five resident rooms on the south hallway, four resident rooms on the north hallway, and in the facility dining room. Findings included: - On 03/01/22 at 10:13 AM, an environmental tour was conducted with, maintenance staff U, which revealed the following concerns: South hallway; 1. A resident's room's flooring contained a dark substance build-up around the edges of the floor. 2. A resident's bathroom floor, in front of the toilet contained a discolored stain area. 3. In a resident's room, a vinyl recliner chair's arm rests contained peeling and cracks over them. 4. The walls in a residents' bathroom, had a dried greenish-brown substance on them. 5. The floors in a residents' room had a brown/gray build-up around the edges of the room. North hallway; 1. A residents room walls, contained a dark substance around the edges. 2. A residents' room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 63 residents with 18 selected for review. Based on observation, interview and record review, the facility failed to review and revise the care plan for one sampled resident (R)47, with continued weight loss. Findings included: - Review of resident (R)47's Physician Order Sheet, dated 02/01/22, revealed diagnoses included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), hiatal hernia (-protrusion of the stomach through an opening in the diaphragm [a muscle that separates the chest from the abdomen), and gastrointestinal reflux disease (GERD backflow of stomach contents to the esophagus) . The resident had a cholecystectomy (removal of the gallbladder) on 09/29/21. The Annual…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 63 residents with 18 selected for review including five residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interview, the facility failed to ensure three of those residents, Resident (R)4, R36, and R53 received monitoring to ensure staff offered bathing per the resident preferences and failed to ensure one resident R53 received appropriate fingernail care. Findings included: - The Medication Review Report, dated 02/16/22, for R53, included diagnoses of psychosis (any major mental disorder characterized by a gross impairment in reality testing), the need for assistance with personal hygiene care, muscle weakness, personality change, delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), traumatic brain injury, and tremor. The Annual Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 63 residents with 18 selected for review, which included three residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to initiate alternative interventions for weight loss for one of the three residents, (R)24's with a weight loss of 6.9% from 12/20/21 to 02/28/22, with a weight loss from 172.5 pounds (lbs.) to 160.6 lbs. in just over two months. Findings included: - Review of resident (R)47's Physician Order Sheet, dated 02/01/22, revealed diagnoses included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), hiatal hernia (-protrusion of the stomach through an opening in the diaphragm [a muscle that separates the chest from 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 · D2022-03-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 63 residents with 18 selected for review including three residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to ensure appropriate services to prevent respiratory infections for the three residents with the failure to ensure oxygen tubing was properly stored when not in use, and failure to date oxygen tubing when changed. The facility failure also included for these three residents; failure to date the humidifier bottle when placed for Resident (R)60, failure ensure the disposable humidifier bottle had water in it and changed timely for R15. These practices increase the risk of the three residents developing a respiratory infection. Findings included: - The Medication Review Report, dated 02/16/22, for R15, included diagnoses of Chronic Obstructive Pulmonary Disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and pneumonia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-07 · 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 reported a census of 63 residents with 18 selected for review including five reviewed for unnecessary medications. Based on record review and interview, the facility failed to accurately act upon pharmacist recommendations to ensure one of the five residents reviewed, Resident (R)39 remained free of unnecessary medications when the facility failed to follow his orders for his psychotropic (class of medications capable of affecting the mind, emotions, and behavior) medication. Findings included: - The Medication Review Report, dated 02/16/22, for R39, included diagnoses of major depressive disorder (major mood disorder) and insomnia (inability to sleep). The Care Plan, dated 10/15/20, revealed that R39 received Trazadone (antidepressant medication) for insomnia, and that the medication had a Black Box Warning (the strongest form of warning required by the Food and Drug Administration that indicates an increased risk of serious adverse reactions associated with the use of a medication). The Consultant Pharmacist Recommendation to Physician, dated 12/29/21, revealed R39…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 reported a census of 63 residents. Based on observation, interview and record review, the facility failed to date six currently used insulin pens when opened for use for three residents Unsampled resident (R) 24,42 56, to ensure quality of the insulin administered to these residents. Findings included: - Observation on at 02/28/22 at 04:27 PM, revealed the following items of concern in the medication cart: 1. Resident (R ) 56's used insulin pens of Levimir and Aspartamine, which both lacked an opened date. 2. R24's used insulin pens of Aspartamine and Novoflex, which both lacked an opened date. 3. R42's used two insulin pens, both of Lispro, and both of which lacked an opened date. On 02/28/22 at 04:30 PM, Interview with Licensed Nurse G, confirmed these six insulin type pens lacked opened dates and verified the staff should date the pens when they removed them from the refrigerator for residents' use. On 03/07/22 Interview with Administrative Licensed Nurse D explained that she would expect staff to label insulin pens when opened and taken out of the refrigerator.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-07-29 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 63 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the daily licensed and unlicensed staff hours, and daily census as required. Findings included:- Observed on 07/27/25 at 09:00 AM, the posted daily staffing sheet only had the first shift staffing information filled out; the second and third shift information was not included, nor were the actual hours worked filled out.Observed on 07/28/25 at 08:00 AM, the posted daily staffing sheet only had the first shift staffing information filled out; the second and third shift information was not included, nor were the actual hours worked filled out.Observed on 07/29/25 at 09:07, the posted staffing sheet only had the first shift information filled out; staffing hours and actual hours were not posted.Review of the daily staffing sheets from 07/29/25, 07/28/25, 07/27/25, 06/22/25, 06/21/25, 06/19/25, 06/16/25, 06/15/25, 06/07/25, 06/02/25, 05/29/25, 05/26/25 revealed…
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
$78,225 in federal fines across 3 penalties.
- $55,991 — penalty dated 2024-09-04
- $14,041 — penalty dated 2023-11-06
- $8,193 — penalty dated 2023-09-21
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 MEDICALODGES, INC. — 18 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 | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 2 of 5 | 3.6 | -1.6 vs chain |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 17 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MEDICALODGES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/22/2009 |
| JALLOW, ALLIE | Individual | W-2 MANAGING EMPLOYEE | — | since 02/14/2019 |
| OTT, RON | Individual | W-2 MANAGING EMPLOYEE | — | since 10/21/1996 |
| COX, GAREN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 02/26/1998 |
| DOLL, GAYLE | Individual | CORPORATE DIRECTOR | — | since 03/10/2005 |
| HINES, SCOTT | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/19/2009 |
| MARSHALL, CAROL | Individual | CORPORATE DIRECTOR | — | since 01/01/2016 |
| CARDENAS, STACI | Individual | CORPORATE OFFICER | — | since 05/28/2013 |
| COOVER, TERESA | Individual | CORPORATE OFFICER | — | since 07/07/2016 |
| LAGER, SHANNON | Individual | CORPORATE OFFICER | — | since 06/15/2013 |
| LANTZ, KATHLEEN | Individual | CORPORATE OFFICER | — | since 10/22/2007 |
| MCBRIDE, TRAVIS | Individual | CORPORATE OFFICER | — | since 11/15/2012 |
| ROHLING MCCORD, CATHERINE | Individual | CORPORATE OFFICER | — | since 06/09/2000 |
| SMITH, PAMELA | Individual | CORPORATE OFFICER | — | since 01/01/2016 |
| WAECHTER HARMON, LORI | Individual | CORPORATE OFFICER | — | since 03/25/2019 |
CMS files one row per role, so the 17 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $189K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175413. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-29, 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.