Access Mental Health

Location & what’s nearby

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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

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.

Staffing

How full it usually is: this home is certified for 45 beds and averages 43.9 residents a day — about 98% occupied, or roughly 1 bed 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.

Weekend coverage: total nurse staffing is 2.34 hrs/resident/day on weekends vs 2.42 on weekdays — 3% thinner on weekends. RN hours go from 0.64 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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.

45 citations, most serious first. The 20 most serious are shown; the remaining 25 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-12-10 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility identified a census of 42 residents. The sample included 12 residents, with one reviewed for behavioral services. Based on observation, record review, and interviews, the facility failed to provide adequate behavioral health services, including resident-centered interventions to address Resident (R)15's auditory hallucinations related to his schizophrenia and bipolar disorder. On 09/23/35, R15 had exit-seeking behaviors as he heard voices telling him he was supposed to discharge from the facility. The facility staff did not report the incident, and the facility did not assess and identify possible triggers or implement interventions to address the auditory hallucinations. R15's mental provider assessed the resident on 10/07/25 but did not address this resident's recent auditory hallucinations or the associated behaviors. On 11/02/25, R15 again had auditory hallucinations telling him to go outside, so R15 entered the door code and exited the facility without staff knowledge or supervision. R15 was outside alone for 1.5 hours, and was located two blocks from the facility,…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2024-10-10 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility reported a census of 43 residents, with six residents sampled and one resident reviewed for the right to be free from physical restraints. Based on interview and record review, the facility failed to ensure Resident (R) 3, who had a history of self-harm and physically and verbally aggressive behaviors, remained free of physical or chemical restraints when on 09/18/24, 09/19/24, and 09/20/24 the resident attempted to injure himself and became combative with staff and the facility staff chemically and physically restrained the resident. The facility failed to identify the resident's medical/behavioral symptoms that warranted the use of chemical restraint, physical restraint of five to six staff, and the use of a bedsheet to further restrain the resident. The resident's record lacked any physician orders related to the use of the restraints, any specific documentation related to assessment of the resident for restraint use and/or person-centered care planning, which included the use of a physical restraints or the least amount of restriction/time possible and/or ongoing…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-10-10 · tag F0742 — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  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 43 residents, with six residents sampled and one resident reviewed for treatment and services for mental/psychosocial concerns. Based on interview and record review, the facility failed to acknowledge and respond appropriately to Resident (R) 3's behaviors which aligned to treatment and services related to his psychosocial disorder and physical aggression related to his diagnoses. The resident made statements such as I will kill my guardian and comments regarding killing himself on 09/18/24 at 05:07 PM. The resident became loud, insisted he had nothing to live for and wanted to kill himself. R3 became very belligerent and combative. R3 stated he just wanted to die and then started to hit his head with his fist, banged his head on the wall, hit himself in his own face with his knee, and five staff assisted in restraining the resident from hurting himself. Resident was crying, yelling, and was relentless to hurt himself. R3 attempted to stab himself with a paperclip. On 09/19/24…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-02-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility reported a census of 45 residents. The six sampled residents included three reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). The facility identified six residents at risk for elopement. Based on observation, interview, and record review the facility failed to provide appropriate supervision, implement interventions, and identify elopement behaviors to prevent the elopement of Resident (R)1, who remained on 30-minutes checks from a prior elopement, eloped again from the facility on 01/28/24 at 04:36 PM, with staff present. The facility staff did not realize R1 was missing until another staff member saw R1 walk past a window outside the building, on 01/28/24 at 05:30 PM. almost an hour after the resident eloped. Review of the 30-minute check log revealed the facility staff failed to check and log on the resident's whereabouts since 01/28/24 at 04:30 PM. This deficient practice placed the resident in immediate jeopardy. Findings included: - The Electronic Health Record (EHR) documented R1 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2024-01-16 · tag F0609 — failed to report abuse allegations — widespread
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to ensure the reporting of incidents of sexual assault and harassment to local law enforcement, as required. The facility failed to provide adequate supervision and care planned interventions to prevent R2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public. On 01/02/24 R2 attempted to grab another resident's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy. Findings included: - R2's Electronic Health Record (EHR) revealed 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2024-01-16 · tag F0610 — failed to investigate and act on abuse reports — widespread
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to protect residents from incidents of sexual assault and harassment the failure to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public area. On 01/02/24, R2 attempted to grab R3's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy, and at risk for negative psychosocial impact of female residents' safety and well-being. Findings included: - R2's Electronic…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-01-16 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public area. On 01/02/24, R2 attempted to grab R3's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy. Findings included: - R2's Electronic Health Record (EHR) revealed a diagnosis of unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility reported a census of 45 residents, with one resident sampled for 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). The facility identified six residents at risk for elopement. Based on observation, interview, and record review, the facility failed to provide adequate supervision, identify likely avenues of exit (including windows), and failed to ensure the windows were secured after Resident (R)1 broke the window out in his room, to prevent elopement. On 01/05/24, R1, who suffers from delusions/hallucinations and wandering, broke the window out in his room and reported he was scared and wanted to leave. Certified Nurse Aid (CNA) D did not provide the supervision of R1, as directed by Licensed Nurse (LN) C. At 08:00 PM, unsupervised R1 went to his room unaccompanied. At 08:01 PM, R1 climbed through the known broken window and eloped from the facility and injured his leg. The staff did not realize R1 was gone until 08:02 PM. At 08:16 PM 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-01-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility identified a census of 45 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, record review, and interviews the facility failed to identify and implement nutritional interventions related to Resident (R) 27's significant weight loss between 01/01/24 to 06/07/24. The facility additionally failed to implement alternative nutritional interventions for R27's ongoing significant weight loss between 08/01/24 and 01/01/25. As a result of the deficient practice, R27 had a significant unplanned weight loss of 19.52 percent (%) and 16.84 % within two three-month periods. This also placed R27 at risk for malnourishment-related complications. Findings included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) documented diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), abnormal weight loss, and history of…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-02-01 · tag F0741 — failed to have staff trained for behavioral health — isolated
  Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility reported a census of 45 residents and identified six residents at risk for 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). Based on observation, interview, and record review, the facility failed to provide sufficient staff with the appropriate competencies and skills sets to meet the behavioral health needs one Resident (R)1, who had known elopement behaviors and a history of an elopement, to prevent an additional elopement from the facility. Findings included: - The Electronic Health Record (EHR) documented R1 had diagnoses which included unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), cannabis (marijuana) abuse, and insomnia (inability to sleep). The 03/01/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 hallucinated (sensing things…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-03 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report allegations of abuse from Resident (R) 17 to the State Agency as required and further failed to ensure all contracted vendors or providers reported allegations of staff to resident abuse to the Administrator immediately. Findings included: - R17's Electronic Medical Record (EMR) included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), major depressive disorder (major mood disorder that causes persistent feelings of sadness), adverse effect of methamphetamines (an illegal stimulant with high addiction potential), and adjustment disorder with anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R17's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R17 had verbal behavioral symptoms…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · E2025-12-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for nine residents, Resident (R) 33, R2, R31, R49, R17, R42, R10, R15, and R16, related to uncomfortable, torn, and/or damaged mattresses with exposed filling on nine mattresses rendering them unsanitizable. Findings included:- Observations on 12/10/2025 at 09:00 AM, during an environmental tour with Maintenance Staff V and Maintenance Staff W, revealed the following concerns for nine residentsR33's mattress was worn.R2's mattress had a tear at the bottom.R31's mattress had multiple tears on the bottom side.R49's mattress had multiple tears on both the bottom and top.R17's mattress had tears along the side, exposing the bed cover, which was worn and ripped.R42's mattress had a tear along the side. R10's mattress had multiple tears/rip areas in the cover at the top of the bed.R15's mattress had multiple tears/rips on 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-10 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for three residents: Resident (R) 5, related to restraint; R1 related to catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid); and R2 related to dental. Findings included:1. R5's Electronic Medical Record (EMR) recorded a Annual Minimum Data Set (MDS) dated [DATE] that documented R5 had a bed rail used daily under the physical restraints (are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) section. During an observation and interview on 12/08/2025 at 09:04 AM. R5 ambulated in the hallway near his room. He opened the door to his room to complete an interview. Further…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-10 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 2's left shoulder limited mobility and shoulder pain and R47s oxygen, refusal of cares, and continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) use. Findings included:1.R2's Electronic Medical Record (EMR) revealed diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) and chronic pain. R2's 10/27/25 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R2's MDS recorded that he had impairment of the upper extremity on one side. R2's was independent for dressing and mobility. R2's 01/24/25 admission MDS documented a BIMS of 15. R2's MDS recorded he had no impairment of his…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-10 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  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 42 residents. The sample included 12 residents. Based on interview and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 47's Electronic Medical Record (EMR) contained appropriate documentation to include physician notifications and R47's refusals to be transferred to the local hospital. Findings included:- R47 's EMR revealed diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and sleep apnea (a disorder of sleep characterized by periods without respirations). R47's [DATE] admission Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R47 rejected evaluation or care daily.…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 42 residents. The sample included 12 residents, with one resident reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record review, and interviews, the facility failed to ensure adequate catheter care within the standards of practice was provided for Resident (R) 1 when staff failed to secure the catheter tubing to R1's leg to prevent pulling and/or dislodgement and also failed to provide catheter care using adequate infection control practices to prevent catheter related urinary tract infections (UTI).Findings included:- R1's Electronic Health Record (EHR) for R1 included diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-10 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 42 residents. Based on observation, record review, and interviews, the facility failed to implement and maintain an effective infection control program when staff failed to provide catheter care using adequate infection control practices and 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) during high contact care for Resident (R)1.Findings Included:- During an observation on 12/09/25 at 01:17 PM, Certified Nurse Aide (CNA) M emptied R1's leg bag into an empty urinal. CNA M entered the room, performed hand hygiene, and applied appropriate EBP. CNA M then emptied the urine collection bag and allowed the drain port of R1's leg bag to come in contact with the side of the urinal. CNA M did not clean or sanitize the drain port pad after emptying the contents of the drain bag. CNA M did not place a cap or other barrier device…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-06-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility reported a census of 42 residents, one central kitchen, and one dining area. Based on observation, interview, and record review, the facility failed to follow sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk for food-borne illnesses. Findings included: - During an initial tour of the facility on 06/17/25 at 09:30 AM with Dietary BB revealed the following areas of concern: In the standing freezer, a package of shredded potatoes was open to air. In a chest freezer, a box of pork sausage patties was open to air. Observation in the dry storage area revealed the following: A package of lemon pudding mix was open to air. A large package of butterscotch chocolate chips was open to air. A large package of Italian dressing mix was open to air. A large can of sliced apples and a small can of sliced mushrooms were dented. In the standing refrigerator, a large package of yellow/white shredded cheese mixture was open to air. During an interview 06/17/25 at 09:45 AM, Dietary BB revealed he was not aware that food…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-06-23 · tag F0880 — failed to prevent and control infections — widespread
  Provide 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 42 residents. Based on observation, record review, and interview the facility failed to maintain an effective infection control program related to a sanitary environment to help prevent cross-contamination and the spread of infections in the laundry, and to ensure appropriate handling, storage, processing, and transportation of linen for the residents of the facility. This placed the residents at risk for infectious disease. Findings included: - Observation on 06/18/25 at 09:33 AM revealed Certified Nurse Aide (CNA) N pushed an uncovered soiled/dirty laundry bin down the hallway with soiled laundry overflowing the container. On 06/18/25 at 09:43 AM CNA N pushed a closed dirty laundry bin with an open laundry basket overflowing with soiled laundry on top of the lid of the closed bin. Observation on 06/23/25 at 02:29 PM, with Laundry Staff U, revealed a wood table in the laundry used for folding resident's clean laundry and processing linen. The table had chipped laminate on the surface and bare wood around the edge of the table resulting in 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-23 · tag F0636 — pattern
  Assess 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 42 residents. The sample included 12 residents. Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAA) that addressed the individual underlying causes, contributing factors and risk factors for five residents. Resident (R)1, R8, R 9, R245, and R195. This placed the residents at risk for inadequate care due to unidentified care needs. Findings included: - R1's Electronic Health Record (EHR) recorded an Annual Minimum Data Set (MDS), dated [DATE] which triggered the Psychotropic Drug Use CAA documented R1 took psychotropic (alters mood or thought) medications to manage schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), depression, and anxiety. The CAA lacked an analysis of the findings. R8's EHR recorded an annual MDS dated 05/18/25 which triggered the Dental Care CAA. The CAA documented R8 had potential for cavities…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$114,739 in federal fines across 3 penalties. 2 Medicare payment denials on record.

• $14,508 — penalty dated 2025-12-10
• $64,643 — penalty dated 2025-06-23
• $35,588 — penalty dated 2025-01-15
• Medicare payment denial — starting 2025-07-26 for 12 days
• Medicare payment denial — starting 2024-02-13 for 16 days

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.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in KS