Elmhaven East
1400 S 15th Street, Parsons, KS 67357 · For profit - Corporation · 45 certified beds · (620) 421-1430 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (67%) 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 15.8% | 17.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 14.6% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 6.3% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star 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 | 2.7% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.4% | 16.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.5% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.4% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.6% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.5% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 45 beds and averages 28.7 residents a day — about 64% occupied, or roughly 16 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.22 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.25 hrs/resident/day on weekends vs 4.05 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.44 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 67% 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 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.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · F2026-06-10 · 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
Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation in the facility's one kitchen to prevent the spread of food borne illness to the residents of the facility. Findings included:- Initial tour of the kitchen on 06/08/2026 at 08:28 AM with Dietary Staff DD revealed the following areas of concern: Numerous baking sheets, baking pans, and cooking pots had black staining on the interior and exterior of the cookware and bakeware. Ground nutmeg and ground cloves dated 11/11/2019. An undated, unsealed bag containing a biscuit, an unsealed, undated loaf of bread, and a box of brown rice dated 05/20/2026 with an expiration date of 03/04/2026. There were food items not clearly dated, which created an inability to confirm what year was intended for those items. One container of ketchup dated 02/12, one large container of picante sauce dated 02/24, one large container of relish dated 03/24, one jar of spicy mustard dated 06/04, one unsealed bag of meat dated 06/04, one unsealed bag of meat dated 06/05, numerous…
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 · F2026-06-10 · 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
Based on interview and record review, the facility failed to ensure the mandatory 12 hours of education was completed for Certified Nurse Aides (CNA)/Certified Medication Aides (CMA) as required. Findings included:- A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA M was hired on 11/20/2024. She had no specific hours tracked for in-service training.CNA O was hired on 01/23/2023. She had no specific hours tracked for in-service training.CNA LL was hired on 07/18/2024. He had no specific hours tracked for in-service training.CNA PP was hired on 07/19/2021. She had no specific hours tracked for in-service training.CNA QQ was hired on 08/16/2024. She had no specific hours tracked for in-service training. Upon request of the CNA in-service hours, the facility provided monthly in-service sign-in sheets for the months from 05/2025 through 05/2026 that included staff names and signatures in attendance. The list lacked staff certification or position. The sheets lacked specific times for the required topics.…
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 before2026-06-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record reviews and observation, the facility staff failed to implement adequate infection control practices related to hand hygiene and sanitization of shared equipment. The facility staff also failed to implement adequate 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) 1 while flushing his urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). Findings included:- Observed on 06/09/2026 at 07:50 AM, R16 had an EBP gown and gloves with signage outside her room. Observed on 06/09/2026 at 07:58 AM, Licensed Nurse (LN) G performed hand hygiene and then donned a gown and gloves and proceeded to apply skin lotion to R16's arms and legs. R16 had a skin tear to her left forearm, a scabbed wound on her left hand, a deep tissue wound to her right heel, and a wound on her right shin that had Steri-strips (adhesive wound closures) on it. LN G did not change gloves or perform hand…
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 before2026-06-10 · 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
Based on interview, observation, and record review, the facility failed to protect the dignity of Resident (R) 16 when staff left her breasts exposed unnecessarily while proving care and did not offer or place to a cover for the exposed areas not being cared for. Findings included:- The Electronic Medical Record (EMR) for R16 documented diagnoses of anorexia nervosa (an eating disorder and serious mental health condition), history of falling, gout (inflammation of the joints), type 2 diabetes mellitus with diabetic neuropathy (a common complication of type 2 diabetes mellitus where chronically high blood sugar damages nerves throughout the body), and major depression. R16's admission Minimum Data Set (MDS), dated 05/06/2026, documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment documented that she used a wheelchair for mobility. The MDS did not indicate R16 used a mechanical lift for transfers. The MDS documented that she required substantial to maximum assistance with oral and personal hygiene, as well as upper-body dressing.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure Resident (R) 7's psychotropic as-needed (PRN) medication had the required 14 days stop date or a specified duration with a physician documented, rationale for the extended duration. Findings included:-R7's Electronic Medical Record (EMR) revealed the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), and dementia (a progressive mental disorder characterized by failing memory and confusion) with delusions and/or hallucinations. R7's 12/10/2025 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R7 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide Resident (R) 3 with a written notification of transfer to the resident and/or his representative as soon as practicable after R3 was transferred to the hospital. Findings included:- R3's Electronic Medical Record (EMR) revealed a diagnosis of severe sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), renal failure (inability of the kidneys to excrete waste, concentrate urine, and conserve electrolytes), and below-the-knee amputation (surgical removal of a body part). R3's 04/27/2026 at 10:04 AM Nurse's Note documented that he lay on his bed staring off. R3's pupils were dilated, and his response was sluggish. R3 slurred his words; he was unable to finish a sentence, unable to communicate what was wrong, and his breathing was rapid. The nurse notified the doctor, and R3 was transported to the hospital by ambulance. R3's EMR lacked evidence that written notification of the transfer was provided to R3 or his representative.…
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 before2026-06-10 · 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 Based on observation, interview, and record review, the facility failed to review and revise Resident (R) 6's Care Plan to reflect her current and accurate advance directives. Findings included:R6's Electronic Medical Record (EMR) documented diagnoses of anxiety, depression, weakness, and hemiplegia (paralysis of one side of the body)and hemiparesis (weakness and paralysis on one side of the body) following 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). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven, indicating a severe impairment. R6's Care Plan dated [DATE] and revised on [DATE] documented that cardiopulmonary resuscitation (CPR) would be initiated when the resident's heart function or respirations ceased. CPR would continue until emergency medical staff arrived to transport R6 to the emergency department. R6's…
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 · D2026-06-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to offer and administer or obtain an informed declination for the influenza (highly contagious viral infection) immunization for Resident (R) 21 and R12. This placed the residents at risk for complications related to influenza infections. Findings included:- R21's Electronic Medical Record (EMR) revealed a signed vaccine record that documented he declined the influenza immunization on 08/09/2023. R21's EMR lacked evidence that the vaccine was offered and/or lacked evidence of informed declination for the 2025 flu season. - R12's EMR revealed a signed vaccine record that documented that her legal representative had declined for her to have the influenza immunization on 05/10/2024. R12's EMR lacked evidence that the vaccine was offered and/or lacked evidence of informed declination for the 2025 flu season. On 06/08/2026 at 01:45 PM, Administrative Nurse E stated there are no vaccine refusals for the 2025/2026 influenza season for R21 and R12. She said that they were verbally offered the immunizations and declined, but it was…
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 · F2025-04-23 · 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 — the official record, unedited, may be distressing
The facility reported a census of 30 residents. Based on observation, interview, and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight consecutive hours as required. This placed the residents in the facility at risk for unsupervised nursing care and services. Findings included: - Review of the facility's Daily Staff Posting from 05/01/24 through 07/30/24, revealed the facility did not have the required eight consecutive hours of RN coverage, as required, on 05/05/24, 06/02/24, 06/16/24, 07/13/24, 07/14/24, 07/20/24, 07/21/24, 07/27/24, and 07/28/24. On 04/23/25 at 08:17 AM, Administrative Nurse E was unable to verify the facility had an RN for eight consecutive hours on the mentioned dates. The facility did not provide a policy for having an RN on duty for at least eight consecutive hours every 24 hours.
- Potential for harm · Ecited before2025-04-23 · tag F0636 — patternAssess 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 had a census of 30 residents. The sample included 14 residents. Based on record review and interview, the facility failed to complete the comprehensive Minimum Data Set Assessment (MDS) for three sampled residents, Resident (R)4, R16, R26, R15, R30, and R22 when staff failed to ensure the triggered Care Area Assessments (CAA) were completed as required. This placed the residents at risk for unmet care needs and inaccurate assessments. Findings included: - Review of R4's Electronic Medical Record (EMR) recorded a quarterly MDS, dated [DATE]. R4's EMR recorded a comprehensive MDS, dated [DATE], which lacked completion of the triggered CAAs, as required. Review of R16's EMR recorded a quarterly MDS, dated [DATE]. R16's EMR recorded a comprehensive MDS, dated [DATE], which lacked completion of the triggered CAA, as required. Review of R26's EMR recorded a quarterly MDS, dated [DATE]. R26's EMR recorded a comprehensive MDS, dated [DATE], which lacked completion of the triggered CAA, as required. Review…
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 20 citations
- Potential for harm · Dcited before2025-04-23 · 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 30 residents with 14 residents sampled, including three residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, when two staff members entered her room during cares. This placed the resident at risk for impaired dignity and embarrassment. Findings included: - Review of R4's Electronic Medical Record (EMR) revealed a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). 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. She was dependent on staff for rolling side to side in bed, toileting, and wheelchair mobility. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 02/25/25, triggered but lacked an analysis of findings. The Quarterly MDS, dated 12/03/24, documented the resident had a BIMS score…
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 · D2025-04-23 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 30 residents with 14 residents sampled. Based on observation, interview, and record review, the facility failed to verify Resident (R) 10's advanced directives (a legal document in which a person specifies what actions should be taken for their health, which may or may not include a do not resuscitate [DNR-decision whether, or not, to withhold medical intervention in the event the resident's heart stops] order). Additionally, the facility failed to ensure R10's DNR was signed by the resident. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care. Findings included: - Review of the Electronic Health Record (EHR) for R10 included diagnoses of Parkinson's disease (a progressive neurodegenerative disorder that primarily affects the central nervous system, leading to both motor and non-motor symptoms), atherosclerotic heart disease of native coronary artery (a condition where plaque builds up inside the coronary arteries, which are the blood vessels that supply oxygen-rich blood to the heart),…
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 · D2025-04-23 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 30 residents, with 14 residents sampled, including five residents reviewed for unnecessary medications. Based on record review, interview, and observation, the facility failed to notify the physician when Resident (R) 8 had a weight gain in 24 hours while on a diuretic (a class of medications used to promote the formation of urine and prevent fluid accumulation). This placed R8 at risk for delayed physician involvement and treatment options. Findings included: - R8's Electronic Medical Record (EMR) documented a diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The 08/22/24 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R8 weighed 289 pounds and took a diuretic. The 08/22/24 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R8 took a diuretic medication. The 02/20/25 Quarterly MDS documented a Brief Interview for Mental Status (BIMS) of 15, indicating…
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 · D2025-04-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 30 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to complete the Minimum Data Set for Resident (R) 7 within the required timeframes. This placed the resident at risk for unidenitfied care needs and inadequate plan of care. Findings included: - R7's Electronic Medical Record (EMR) documented a diagnosis of schizoaffective disorder (a mental illness characterized by symptoms of both schizophrenia (like hallucinations and delusions) and a mood disorder (like bipolar disorder or depression), panic disorder [episodic paroxysmal anxiety], irritability and anger, seizure disorder (violent involuntary series of contractions of a group of muscles), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety (class of medications that calm and relax people), insomnia (inability to sleep), and depressive disorder (major mood disorder which causes persistent feelings…
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 · D2025-04-23 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 30 residents. The sample included 14 residents with one sampled for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, interview, and record review, the facility failed to address catheter care on Resident (R) 83's baseline care plan. This deficient practice had the risk for adverse outcomes and complications for R83 due to uncommunicated care needs. Findings: - R83's Electronic Medical Record (EMR) documented a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The 04/14/25 admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) of 11, indicating moderately impaired cognition. The MDS recorded R83 required assistance from staff with activities of daily living (ADLs) and had a catheter. The 04/14/25 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) R83 had a diagnosis 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 · D2025-04-23 · 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 30 residents with 14 residents sampled, including two residents reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to recognize, assess, and implement interventions consistent with Resident (R)26's current level and/or mode of assistance required for transfers. This placed the resident at risk for injury and further ADL decline. Findings included: - R26's Electronic Medical Record (EMR) revealed a diagnosis of cerebrovascular accident (CVA-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 Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required substantial to maximal assistance of staff for transfers and had an impairment on one side of her lower extremity (LE). The Functional Abilities 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 · Dcited before2025-04-23 · 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 30 residents with 14 residents sampled, including four residents reviewed for positioning and range of motion (ROM). Based on observation, interview and record review, the facility failed to perform restorative cares for Residents (R)4, R26, and R16 and failed to properly position R4 while in her Geri-chair (a specialized wheelchair). Findings included: - R4's Electronic Medical Record (EMR) revealed a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). 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. She had a limitation in functional ROM on both sides of her lower extremities and was dependent on staff for transfers and wheelchair mobility. The resident did not receive restorative cares during the assessment period. The Functional Ability Care Area Assessment (CAA), dated 02/25/25, triggered but lacked 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 · D2025-04-23 · 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 30 residents with 14 residents selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to properly inform families of the risks and benefits associated with psychotropic (alters mood or thoughts) medications for Resident (R) 8 and R7. It also failed to properly monitor for adverse reactions and behaviors related to an antipsychotic medication (class of medications used to treat major mental conditions which cause a break from reality) for R8. These deficient practices placed the affected residents at risk for adverse effects associated with the use of psychotropic medications. Findings: - R8's Electronic Medical Record (EMR) documented a diagnosis of anxiety (class of medications that calm and relax people), insomnia (inability to sleep), unspecified psychosis (any major mental disorder characterized by a gross impairment in reality perception), major depressive disorder (major mood disorder which causes persistent feelings of sadness), 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 · Dcited before2025-04-23 · 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 30 residents. The sample included 14 residents. Based on interviews, record reviews, and observation, the facility staff failed to implement adequate and acceptable infection control practices for Resident (R) 15 whose oxygen tubing was allowed to drag the floor as he wheeled himself through the facility. This deficient practice placed the resident at risk of infections. Findings included: - During an observation on 04/21/25 at 08:30 AM, R15 sat in the dining room in his wheelchair wearing an oxygen nasal cannula (a device that delivers extra oxygen through a tube and into your nose). R15's oxygen tubing was wrapped around part of his wheelchair and dragging on the floor. During an observation on 04/21/25 at 10:13 AM, R15 was wearing continuous oxygen, and his oxygen tubing was tangled on his wheelchair axle and dragging on the floor as he wheeled himself down the hall. During an observation on 04/21/25 at 01:31 PM, R15 was sat in his room watching TV and his oxygen tubing was on the floor under his wheelchair. During an observation on 04/22/25 at…
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 before2023-08-10 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - The Physician Order Sheet (POS), dated 07/03/23, documented Resident (R)20 had a diagnosis of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required total assistance of two staff for bed mobility, transfers, and dressing. He had impairment in range of motion (ROM) to his bilateral (both sides) lower extremities. The resident did not receive restorative care during the assessment period. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/05/23, documented the resident required extensive to total assistance of one to two staff for most ADLs. The Quarterly MDS, dated 04/20/23, documented the resident had a BIMS score of 15, indicating intact cognition. He required extensive assistance of two staff for bed mobility and dressing and total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-10 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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 35 residents with 14 residents sampled, that included six residents reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide restorative services to maintain, improve, or prevent avoidable decline in ROM and mobility for four Residents (R)1, R 11, R 20, and R 28, of the six residents reviewed. Findings included: - The Physician Order Sheet (POS) dated 06/29/23, documented Resident (R)1 had a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, that indicated severe cognitive impairment. She required total assistance of two staff for bed mobility, transfers, dressing, and toilet use. She had impairment in range of motion (ROM) on both sides of her lower extremities. She received active range of motion (AROM) and passive range…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-10 · 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 35 residents with 14 residents selected for review. Based on interview and record review, the facility failed to fully complete comprehensive Minimum Data Set (MDS) assessment Section V Care Area Assessment Summary (CAA) for Resident (R)19 and R 10 to include an analysis and rationale for care planning decisions. This placed these residents at risk for not accurately reflecting each resident's status and needs to develop an individualized comprehensive plan of care. Findings included: - Review of Resident (R)19's Physician Order Sheet, dated 06/30/23, revealed diagnoses that included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), hemiplegia (paralysis on one side of the body,) and chronic pain. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive deficit. The resident had delusions (untrue persistent belief 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 · D2023-08-10 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 35 residents with 14 residents selected for review. Based on observation, interview and record review, the facility failed to complete a significant change comprehensive assessment for one selected Resident (R)19, when this resident discharged from hospice services, as required to ensure accurate needed cares provided. Findings included: - Review of Resident (R)19's Physician Order Sheet, dated 06/30/23, revealed diagnoses included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), hemiplegia (paralysis on one side of the body), and chronic pain. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive deficit. The resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident required extensive assistance of one staff for bed mobility, transfer, dressing,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · 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 reported a census of 35 residents with 14 residents selected for review, which included three residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure staff provided increased nutritional support, alternative pressure relieving measures, and sanitary dressing changes for one Resident (R)5 following surgical debridement (removal of dead tissue) of her stage four pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle. Slough [dead tissue, usually cream or yellow in color] or eschar [dead tissue] may be present on some parts of the wound bed. Often includes undermining and tunneling). Findings included: - Review of Resident (R)5's Physician Order Sheet, dated 07/01/23, revealed diagnoses included multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord) and epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set (MDS), dated [DATE], assessed 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 · D2023-08-10 · 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 35 residents with 14 residents selected for review, that included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure staff provided safe wheelchair transport to prevent accidents for one Resident (R)28, of the three selected residents. Findings included: - Review of Resident (R)28's Physician Order Sheet, revealed a diagnosis of malignant (cancerous) brain tumor. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognitive status. The resident required extensive assistance of staff for locomotion. The resident had no impairment in functional range of motion in the upper or lower extremities. The resident utilized a walker or wheelchair for mobility. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 07/13/23, assessed the resident's impairment to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 35 residents with six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility consulting pharmacist failed to identify the facility failure to monitor the effectiveness of warfarin (a blood thinner medication) for one Resident (R)10, of the six reviewed residents. Findings included: - Review of Resident (R)10's Physician Order Sheet, dated 07/05/23, revealed diagnoses included atrial flutter (rapid, irregular heartbeat) and cerebral vascular accident (CVA, 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 Annual Minimum Data Set (MDS), dated [DATE], assessed the resident's Brief Interview for Mental Status (BIMS) score of 11, that indicated moderate impairment in cognition. The resident received seven days of an anticoagulant (medication commonly known as blood thinners, used to prolong clotting time) and diuretic (medications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · 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 reported a census of 35 residents with 14 residents selected for review, that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff monitored the warfarin (a blood thinner medication) for one Resident (R)10, to prevent adverse reactions. Findings included: - Review of Resident (R)10's Physician Order Sheet, dated 07/05/23, revealed diagnoses included atrial flutter (rapid, irregular heartbeat) and cerebral vascular accident (CVA, 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 Annual Minimum Data Set (MDS), dated [DATE], assessed the resident Brief Interview for Mental Status (BIMS) score of 11, that indicated moderate impairment in cognition. The resident received seven days of an anticoagulant (medication commonly known as a blood thinner, to prolong the clotting time) and diuretic (medication to promote…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 35 residents with 14 residents selected for review, that included six residents for review of unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for insulin (a medication used to lower blood sugar) administration for one Resident (R)2. Findings included: - Review of Resident (R)2's Physician Order Sheet, dated 07/03/23, revealed diagnosis of diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Care Plan, revised 06/08/23, instructed staff to administer medications as ordered by the physician and obtain blood glucose levels as ordered by the physician. On 02/16/23, the physician instructed staff to administer the following sliding scale insulin (dose of insulin base on blood sugar results) to the resident. Novolog sliding scale insulin, three times a day, before meals: If the resident's blood sugar was less than 70 mg/dL (milligrams per deciliter), inform the provider. If the resident's blood sugar…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-10 · 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 35 residents with 14 residents sampled, that included two residents reviewed for bowel and bladder. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure to provide appropriate urinary catheter care to prevent urinary tract infections (UTI) for the two reviewed dependent Residents, (R)8 and R 20. Findings included: - The Physician Order Sheet (POS), dated 06/30/23, documented Resident (R)8 had a diagnosis of neuromuscular dysfunction of the bladder (condition where the muscles and nerves which control the bladder do not work properly due to illness or injury). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required total assistance of one staff for toilet use and had an indwelling urinary catheter (catheter drains urine from your bladder into a bag outside your body). 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.
- No harm found · C2025-04-23 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Findings included: - Review of the facility's Daily Staffing Sheets, for the past 30 days, revealed the actual hours worked had not been completed on the daily staffing sheets. On 04/23/25 at 08:17 AM, Administrative Nurse E stated she was unaware the daily staff postings needed to include the actual hours worked. The facility policy for Posting Direct Care Daily Staffing Numbers, revised July 2016, included: The facility shall post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents, including the actual time worked during that shift for each category.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WOODWORTH ENTERPRISES, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/1992 |
| HOPPER, SHARLA | Individual | W-2 MANAGING EMPLOYEE | — | since 10/15/2017 |
| WOODWORTH, BRADLEY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 04/18/2014 |
| WOODWORTH, WESLEY | Individual | W-2 MANAGING EMPLOYEE | — | since 03/20/2000 |
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.
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.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $376K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 175415. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, 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.