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Pratt Health And Rehab

1221 Larimer Street, Pratt, KS 67124 · For profit - Limited Liability company · 45 certified beds · (620) 672-6541 Medicare & Medicaid certified

Call the home — (620) 672-6541 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,901 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • 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
Worth asking about
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,901 in federal fines (most recent 2025-04-03)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
314 S Main St · (620) 388-4191 · Call to confirm hours
Pharmacy
1108 E 1st St · (620) 672-5584 · Call to confirm hours
Grocery
Dillons0.7 mi
1108 E 1st St · (620) 672-5597 · Call to confirm hours
Park
N Mound St · (620) 672-6446 · Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.8%17.9%15.4%better
Long-stay residents who lose too much weight2.4%4.9%5.4%better
Long-stay residents with a catheter left in their bladder3.6%1.6%0.9%worse
Long-stay residents with a urinary tract infection0.7%2.9%2.0%better
Long-stay residents with depressive symptoms6.8%6.5%6.5%typical
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.5%4.3%3.3%worse
Long-stay residents whose ability to walk worsened13.7%16.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.7%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine97.7%95.5%95.3%typical
Long-stay residents with pressure ulcers3.9%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control17.2%22.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table27.3%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Short-stay residents rehospitalized after admission26.1%22.4%22.6%worse
Short-stay residents with an outpatient ER visit10.5%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.521.801.67typical
Long-stay outpatient ER visits per 1,000 resident days2.362.131.80worse

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

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

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

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

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

54.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.8%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
63.3%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 63.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.8%CMS range 42.2–64.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.0–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge53.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge46.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.1–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.85
RN hours/ resident / day
0.53
LPN hours/ resident / day
2.37
Aide hours/ resident / day
3.76
Total nurse hours/ resident / day
0.51
RN hoursweekends
47.5%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 45 beds and averages 39.2 residents a day — about 87% occupied, or roughly 6 beds typically open. It runs fairly full. 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 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 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 3.22 hrs/resident/day on weekends vs 3.98 on weekdays — 19% thinner on weekends. RN hours go from 0.99 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2026-03-17)
9
at the previous standard inspection (2024-04-17)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with three residents sampled for safety related to transportation outside the facility. Based on observation, interview, and record review, the facility failed to ensure that staff provided a safe environment, free of accident hazards during transportation in the facility van. On 03/11/25 at approximately 09:20 AM Certified Nurse Aide (CNA) C failed to ensure Resident (R)1 was safely secured in the facility van before operating the vehicle. CNA C began to drive the van and realized R1 did not have a seatbelt on. CNA C then stopped the vehicle and R1 fell out of the wheelchair onto the floor of the facility van and injured his head, face and left arm. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) documented R1 had diagnoses which included diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), long-term use 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 · Past Non-Compliance
  • Actual harm · G2022-07-28 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure staff identified and promptly responded to signs of pain expressed by cognitively impaired Resident (R)12, when the resident had two fractured ribs and staff did not offer the resident non-pharmacological pain interventions or as needed (PRN) pain medications. Findings included: - Resident (R)12's signed Physician Orders dated 07/01/22 revealed the following diagnoses: Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), schizoaffective disorders (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder ), dementia with behavioral disturbance (major mood disorder),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-03-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions for Resident (R) 8, who had dressing changes to a pressure ulcer daily. The facility also failed to implement a complete water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, or chronic lung diseases). Findings included:-R8's Electronic Medical Record (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, cardiac murmur (abnormal sound), and hypertension (elevated blood pressure). R8's Quarterly…

    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 · D2026-03-17 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 38 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide Resident (R) 8, R10, and R17, or their representative, a Notice of Medicare Non-coverage (NOMNC) when skilled services ended.Findings included:-A review of R8's Electronic Medical Record (EMR) documented that her Medicare Part A episode began on 10/23/25 and ended on 01/09/26. Review of R8's clinical record and facility-provided information lacked evidence that R8 was issued a SNF NOMNC as required. A review of R10's EMR documented that his Medicare Part A episode began on 06/27/25 and ended on 08/21/25. Review of R10's clinical record and facility-provided information that lacked evidence of R10 was issued a SNF NOMNC as required. A review of R17's EMR documented that his Medicare Part A episode began on 05/03/25 and ended on 07/22/25. Review of R17's clinical record and facility-provided information that lacked evidence of R17 was issued a SNF NOMNC as required. On 03/16/26 at 02:28 PM,…

    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 · D2026-03-17 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 38 residents. The sample included 12 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 29 and R40 and their representative were provided with a written notification of transfer, that included a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable. The facility failed to ensure R40 had a discharge summary and recapitulation of stay completed upon her discharge from the facility. Findings included:1. R29's Electronic Medical Record (EMR) recorded a Discharge Minimum Data Set (MDS) dated [DATE], which documented an unplanned discharge to an acute hospital with a return anticipated.R29's Entry MDS dated 07/18/25 documented a re-entry to the facility from an acute hospital.R29's Notice of Transfer form, dated 07/10/25, documented that the form was provided to the resident's representative. The Notice 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-17 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with 16 residents selected for review, which included one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to maintain Resident (R)28's dignity when in bed with only his brief on, to expose himself to the residents, staff and visitors that would go by his room. Findings included: - Review of Resident (R)28's electronic medical record revealed diagnoses that included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function. The resident had impairment in functional range of motion on one side of his upper and lower extremities. The resident was dependent on staff for activities of daily living.…

    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 before2024-04-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with 16 residents sampled. Based on observation, record review, and interview, the facility failed to revise the care plan with effective interventions for Resident (R)12 related to lack of wheelchair foot pedals and R 18, related to inability to self-administer medications. Findings included: - Review of Resident (R)12's electronic medical record (EMR), revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS), dated 12/09/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He used a wheelchair for mobility and required substantial to maximal assistance for mobility 150 feet and partial to moderate assist for mobility of 50 feet while in the wheelchair. The Activities of Daily Living (ADL)Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/09/23,…

    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 · D2024-04-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with 16 selected for review with one resident reviewed for activities of daily living for dependent residents. Based on observation, interview and record review, the facility failed to ensure one Resident (R)28 received facial hair grooming opportunities. Findings included: - Review of Resident (R)28's electronic medical record revealed diagnoses that included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function. The resident had impairment in functional range of motion on one side of his upper and lower extremities. The resident was dependent on staff for activities of daily living. The Cognitive Loss Care Area Assessment (CAA) dated…

    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 · D2024-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with 16 residents selected for review which included three residents reviewed for skin issues. Based on observation, interview, and record review, the facility failed to monitor and provide sanitary dressing change for one, Resident (R)18's venous ulcer, of the three residents reviewed for skin issues. Findings included: - Review of Resident (R)18's electronic medical record, revealed diagnoses that included chronic embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) of the deep veins of the left lower extremity, edema (swelling resulting from an excessive accumulation of fluid in the body tissues,) and paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) personality. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of six, which…

    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 · D2024-04-17 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    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 41 residents with 16 residents selected for review, that included one resident reviewed for vision. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)14, received vision care. Findings included: - Review of Resident (R)14's electronic medical record revealed diagnoses that included diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and major depressive disorder. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status(BIMS) score of 10, which indicated moderate cognitive impairment. The resident had adequate vision with corrective lenses. The Cognitive Loss Care Area Assessment, (CAA) dated 06/21/23, assessed the resident had risk factors of social isolation and increased anxiety. The Care Plan, reviewed 04/08/24, instructed staff the resident was at risk for potential alterations in his visual status related to use…

    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 before2024-04-17 · 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 41 residents with 16 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to safely transport one Resident (R)12 in his wheelchair by failing to have foot pedals in place while propelling him in his wheelchair. Findings included: - Review of Resident (R)12's electronic medical record (EMR), revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS), dated 12/09/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He used a wheelchair for mobility and required substantial to maximal assistance for mobility 150 feet and partial to moderate assist for mobility of 50 feet while in the wheelchair. The Activities of Daily Living (ADL)Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/09/23, documented the resident would experience further ADL decline. 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
  • Potential for harm · Dcited before2024-04-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with 16 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure three Residents (R)18, R34 and R35, of the five residents were monitored for adverse effects of antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications in a timely manner. Findings included: - Review of Resident (R)18's electronic medical record, revealed diagnoses that included richronic embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) of the deep veins of the left lower extremity, edema (swelling resulting from an excessive accumulation of fluid in the body tissues,) and paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) personality. The Annual Minimum Data Set…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-04-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 41 residents. Based on observation, interview, and record review, the facility to properly dispose of a used Fentanyl (a skin patch used to treat severe pain) after staff removed the medicated patch from Resident (R)38. Findings included: - On 04/16/24 at 10:51 AM, Licensed Nurse (LN) G removed a used Fentanyl patch (a skin patch used to treat severe pain) from the hip of Resident (R)38. After removing the patch, LN G folded the patch with the sticky side together and threw it into the trash can in the resident's room. On 04/16/24 at 10:51 AM, LN G stated she always threw the used Fentanyl patches into the trash can and was unaware the patches needed to be disposed of in a special manner. On 04/17/24 at 10:50 AM, Administrative Nurse D stated the Fentanyl patches should not be disposed of in a resident's trash can. Administrative Nurse D stated she expected the staff to dispose of the patches per facility policy. The facility policy for Receiving Pharmacy Products and Services from Pharmacy, effective 04/01/22, included: Used transdermal system…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-17 · 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 reported a census of 41 residents. Based on observation, interview, and record review, the facility failed to monitor and provide sanitary dressing change for one, Resident (R)18's venous ulcers. Findings included: - Review of Resident (R)18's electronic medical record, revealed diagnoses that included chronic embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) of the deep veins of the left lower extremity, edema (swelling resulting from an excessive accumulation of fluid in the body tissues,) and paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) personality. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognitive status. The resident had no venous ulcers. The resident had no impairment in functional range of motion in her…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-28 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility census totaled 43 residents with 12 residents included in the sample. Based on interview and record review the facility failed to provide a bed hold notification with each facility-initiated hospital transfer. (Resident (R)39) Findings included: - R39's medical record revealed a facility-initiated hospitalization transfer on 07/26/22. R39's medical record lacked evidence of a Bed Hold policy notification to the resident or resident representative. Interview with Administrative Staff L on 07/27/22 at 07:10AM revealed the facility did not give Bed Hold notification forms to the resident or resident representative upon transfer to the hospital. Review of the 05/2022 Bed Hold policy revealed the purpose of the policy was to provide residents and family members/legal representatives information upon transfer to the hospital or upon any medical/therapeutic leave. The policy noted every resident had the right to be informed of the bed hold policy. The facility failed to provide a bed hold notification at the time of R39's facility-initiated hospital transfer.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-28 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 43 residents, with 12 in the sample. Based on interview and record review the facility failed to complete a significant change comprehensive assessment for Resident (R)33. Findings included: - R33's pertinent diagnoses from the Electronic Health Record (EHR) documented repeated falls and dementia (progressive mental disorder characterized by failing memory, confusion). The 12/27/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R33 had no behaviors and required limited assistance of one staff with all Activities of Daily Living (ADL). The 03/29/22 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition. R33 required limited assistance of one staff for ADL's. The 06/29/22 Quarterly MDS documented a BIMS of 00, indicating severely impaired cognition. R33 had verbal behaviors and rejection of care one to three days of the seven-day look back period. R33 required limited assistance of two staff for transfers and limited assistance of one staff for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-28 · 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

    The facility reported a census of 43 residents with 12 residents in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan to include the use of oxygen (O2) for R27. Findings included: - The 07/02/22 signed Physician's Orders for R27 revealed the diagnosis of chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 03/20/22 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) revealed a score of 12, indicating moderate cognitive impairment. The MDS did not note the resident's oxygen therapy. The Care Plan dated 04/24/2020 revealed R27 had COPD related to a history of smoking. The staff were to monitor R27 for difficulty breathing on exertion and monitor for signs and symptoms of acute respiratory insufficiency. The care plan lacked use of O2 therapy on the care plan. Review of the Medication Administration Record and the Treatment Administration Record lacked documentation 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-28 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 43 residents with 12 residents in the sample. Based on observation, interview, and record review the facility failed to update the care plan to include fall prevention interventions for Resident (R)12 and R33. Findings included: - R33's pertinent diagnoses from the Electronic Health Record (EHR) documented repeated falls and dementia (progressive mental disorder characterized by failing memory, confusion). The 12/27/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition and documented R33 had no falls. The 03/29/22 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition and documented R33 had no falls. The 07/26/22 Care Plan documented that staff were to toilet R33 every two hours and as needed. The Fall Investigations for 06/17/22 and 07/04/22 documented an intervention for staff to toilet R33 every hour, to prevent further falls. The Care Plan lacked the updated fall prevention interventions from 06/17/22 an d07/04/22 to toilet the resident every…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-28 · 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 census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure the fall prevention interventions were implemented to prevent further falls for Resident (R)12 and R33. Findings included: - R12's pertinent diagnoses from the Electronic Health Record (EHR) documented: Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), schizoaffective disorders (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder ), dementia with behavioral disturbance (major mood disorder), unsteadiness on feet, and tremors (involuntary movements of arms and legs). The 05/18/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. R12 had two or more falls…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 43 residents with 12 in the sample. Based on observation, interview, and record review the facility failed to obtain an order for the oxygen use administered to R27 per nasal cannula. Findings included: - The 07/02/22 signed Physician's Orders for R27 revealed the diagnosis of chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 03/20/22 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) revealed a score of 12, indicating moderate cognitive impairment. The MDS did not note the resident's oxygen therapy. The Care Plan dated 04/24/2020 revealed R27 had COPD related to a history of smoking. The staff were to monitor R27 for difficulty breathing on exertion, monitor for signs and symptoms of acute respiratory insufficiency, and for signs and symptoms of infection. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) lacked documentation of R27's oxygen…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-28 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 43 with 12 residents in the sample, five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the licensed nursing staff administrated insulin (hormone which regulates blood sugar) as ordered to Resident (R)27. Findings included: - The signed Physicians Orders dated 07/02/22 revealed diagnosis of type two diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) for R27. The 03/20/22 Annual Minimum Data Set(MDS) revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R27 received daily insulin injections in the seven-day observation period. The Care Plan, revised on 07/07/22, revealed R27 had diabetes mellitus type 2 and the staff were to administer diabetes medication as ordered by the physicians and monitor and document for side effects and effectiveness. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to administer psychotropic medication as ordered for Resident (R)12's behaviors. Findings included: - Resident (R)12's signed physician orders dated 07/01/22 revealed the following diagnoses: Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), schizoaffective disorders (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder ), dementia with behavioral disturbance (major mood disorder), unsteadiness on feet, and tremors (involuntary movements of arms and legs). The 05/18/22 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident had physical behaviors four to six…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,901 in federal fines across 1 penalty.

  • $14,901 — penalty dated 2025-04-03

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to MISSION HEALTH COMMUNITIES — 30 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.8+1.2 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 4 of 52.9+1.1 vs chain
Quality measures 3 of 52.9+0.1 vs chain
The other 29 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Colby Operator, LLCColby, KS 1 of 5Dickson Health And RehabDickson, TN 1 of 5Hutchinson Operator, LLCHutchinson, KS 1 of 5Kaw River Care And RehabEdwardsville, KS 1 of 5Lincoln Care And RehabWichita, KS 1 of 5North Ridge Health And RehabNew Hope, MN 1 of 5Providence Living CenterTopeka, KS 2 of 5Columbus Health and RehabColumbus, WI 2 of 5Edwardsville Care And RehabEdwardsville, KS 2 of 5El Dorado Care And RehabEl Dorado, KS 2 of 5Spring Hill Care And RehabSpring Hill, KS 3 of 5Chase County Care And RehabCottonwood Falls, KS 3 of 5Eskridge Care And RehabEskridge, KS 3 of 5Lansing Care And RehabLansing, KS 3 of 5McPherson Operator, LLCMcPherson, KS 3 of 5Neodesha Care And RehabNeodesha, KS 3 of 5Parkway Operator LLCEdwardsville, KS 3 of 5Pittsburg Care And RehabPittsburg, KS 3 of 5Rolling Hills Health And RehabWichita, KS 3 of 5Wilson Care And RehabWilson, KS 4 of 5Arma Operator, LLCArma, KS 4 of 5Onaga Operator, LLCOnaga, KS 4 of 5Oswego Operator, LLCOswego, KS 4 of 5Peabody Health And RehabPeabody, KS 4 of 5Smith Center Health And RehabSmith Center, KS 4 of 5Wakefield Care And RehabWakefield, KS 5 of 5Botkin Care And RehabWellington, KS 5 of 5Downs Care And RehabDowns, KS 5 of 5Wellington Health And RehabWellington, KS

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

Who owns this facility

Owner / managerTypeRoleShareSince
KANSAS OPERATOR LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/25/2015
BARRES, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
T AND C CAPITAL ASSETS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
WINDWARD HEALTH PARTNERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
CRINO, BRYANIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
FEUER, SCOTTIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
LINDEMAN, STUARTIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 02/26/2015
PASSERO, JOSEPHIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/26/2015
YOAKUM, JAMIEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/21/2024
MISSION HEALTH COMMUNITIES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/26/2015

CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$4.3M
Net patient revenuemost recent cost report
+3.3%
Operating marginrevenue minus expenses
$267K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 11%Other / private 19%

About 71% 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 $267K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$266per resident / day
operating cost
$8,089per month
≈ monthly operating cost
$275per day
avg. revenue, all payers

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

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175315. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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