Apostolic Christian Home
511 Paramount Street, Sabetha, KS 66534 · Non profit - Church related · 76 certified beds · (785) 284-3471 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,397 in federal fines (most recent 2024-06-10)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.0% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.6% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 2.9% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 8.6% | 6.5% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.8% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.3% | 16.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 11.3% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.6% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.5% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.7% | 18.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.3% | 1.9% | 1.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.73 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.21 | 2.13 | 1.80 | better |
‡ 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.
36.2% 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 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 36.2%CMS range 26.9–51.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 5.8–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.0%CMS range 3.6–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 76 beds and averages 58.6 residents a day — about 77% occupied, or roughly 17 beds typically open. It usually has some room. 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 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.72 hrs/resident/day on weekends vs 4.33 on weekdays — 14% thinner on weekends. RN hours go from 1.00 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-06-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 60 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide a safe environment, free from preventable accidents for Resident (R) 1. On 05/29/24 at 12:15 PM, Transportation FF strapped R1's wheelchair into the facility's transportation van but did not place the seatbelt around R1. When Transportation FF braked before making a turn, R1 slid out of her wheelchair onto the van floor. R1 was taken to the hospital for evaluation where she was found to have left tibia (bone in the lower leg) and fibula (bone in the lower leg) fractures as a result of the accident. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of pain, fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), and weakness. The admission Minimum Data Set (MDS) dated 04/17/24, documented R1 had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-06-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents, with 10 reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure staff provided Resident (R)52 with his call light when he went to bed, resulting in a fall in which R52 obtained a right trimalleolar ankle fracture (a break in the lower leg section that form your ankle joint). The facility further failed to assess residents for safe lift chair use, after falls out of a lift recliner for R52 and R36. The facility failed to follow R36 and R46's plan of care which resulted in falls and failed to implement meaningful, resident centered interventions for R14 and R57. This placed the residents at risk for further falls and avoidable injuries. Findings included: - The Electronic Medical Record (EMR) for R52 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), neurocognitive disorder with Lewy bodies (a type of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-18 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 58 residents and one kitchen. Based on record review and interviews, the facility failed to provide the services of a full-time certified dietary manager for the 58 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 12/16/24 at 07:26 AM, during the initial tour of the kitchen, Dietary Staff BB stated she had started the certified dietary manager course three years ago. Dietary Staff BB stated she had completed three months of the course before staffing shortages at the facility required her to return full-time in dietary. Dietary Staff BB stated the Registered Dietician (RD) came to the facility monthly. On 12/18/24 at 01:10 PM, Administrative Staff A stated he was aware Dietary Staff BB was not certified. Administrative Staff A stated that was something that he would investigate. The Facility's Dietitian policy revised November 2024 documented that a qualified, competent, and skilled dietitian would help oversee the food and nutrition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-12-18 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 58 residents. The sample included 15 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 58 residents residing in the facility. Findings Included: - On 12/18/24 an inspection of the Facility Assessment was completed. The assessment was revised on 06/28/2024. A review of the evaluation revealed the following: The assessment identified the average daily staffing required for the facility but failed to identify the specific staffing levels needed and the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse's Aides (CNA) needed for each unit, shift, and per census. The assessment lacked staffing levels required for each shift, including evenings and weekends. On 12/18/24 at 12:45 AM, Administrative Staff A stated the facility assessment was just revised. He stated he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-18 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 58 residents. The sample included 15 residents with five reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to ensure the residents were provided foot pedals during wheelchair transports for Resident (R) 23, R36, R46, R34, R40, and R33. This placed the residents at risk for preventable accidents and injuries due to unmet care needs. Findings Included: - On 12/16/24 at 08:16 AM, R23, a severely cognitively impaired resident, sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline). R23 had socks on both feet. Certified Nurse Aide (CNA) O pushed R23 in his Broda chair and R23's feet slid along the floor before he lifted his legs. On 12/17/24 at 07:18 AM, Staff pushed R36 in her wheelchair with no foot pedals. Staff repeatedly told R36 to keep her feet up. On 12/17/24 at 07:20 AM, Staff pushed R46, a cognitively impaired resident, in her wheelchair with no foot pedals. Staff repeatedly asked R46 to keep her feet up. On 12/17/24 at 09:47 AM, R23 sat upright in 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.
- Potential for harm · Ecited before2024-12-18 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 58 residents. The sample included 15 with five residents reviewed for drug regimen review. Based on interviews, observations, and record review, the facility failed to ensure the Consulting Pharmacist (CP) identified and made recommendations related to Residents (R) 55, R8, R52, and R32's indications for their antipsychotic medications (a class of medications used to treat major mental conditions that cause a break from reality). This placed the residents at risk for unnecessary psychotropic (alters mood or thoughts) medications and related complications. Findings Included: - The Diagnosis tab within R55's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), fatigue, and pain. R55's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eleven indicating moderate cognitive impairment. The MDS documented she was independent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-18 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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 Diagnosis tab of R32's Electronic Medical Record (EMR) documented diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), dementia (a progressive mental disorder characterized by failing memory and confusion), protein-calorie malnutrition, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), chronic pain, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), insomnia (inability to sleep), chronic pain, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dysuria (painful urination), The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which documented severely impaired cognition. The MDS documented R32…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 112's protected health information (PHI) private on a medication cart parked in the main dining room. This placed R112 at risk for impaired privacy. Findings included: - On 12/17/24 at 07:37 AM, an observation revealed a medication cart parked in the main dining room with a laptop computer sitting on the top, Licensed Nurse (LN) G walked away from the medication cart and into the dining room. LN G left the computer screen unlocked and open and R112's PHI was on the screen, visible to all who passed by the medication cart. The information visualized included R112's medications, date of birth , allergy information, and code status. On 12/18/24 at 11:55 AM, Licensed Nurse (LN) H stated the medication cart should be double locked, the computer screen should be closed, or the PHI should be hidden from view. On 12/18/24 at 12:20 PM, Administrative Nurse D stated she expected the nursing staff to close the computer screen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 58 residents. The sample included 15 residents with 15 reviewed for care plan revisions. Based on interviews, observations, and record reviews, the facility failed to revise Resident (R) 33's Care Plan to reflect his increased behavioral episodes. The facility additionally failed to revise R32's Care Plan to reflect her sleeping preferences. This deficient practice placed both residents at risk for impaired care due to uncommunicated care needs. Findings Included: - The Diagnosis section within R33's Electronic Medical Records (EMR) included diagnoses of epilepsy (brain disorder characterized by repeated seizures), seizures (violent involuntary series of contractions of a group of muscles), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), insomnia (difficulty sleeping), aphasia (difficulty speaking), major depressive disorder (major mood disorder), and cerebral infarction (stroke - sudden death of brain cells due to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 58 residents. The sample included 15 residents with two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing heel protectors or boots were in place for Resident (R) 34 who had a pressure-related injury on her left heel. These deficient practices placed R34 at risk for complications related to further skin breakdown and worsening of pressure ulcers. Findings included: - R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of a pressure ulcer of the left heel, dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 58 residents. The sample included 15 residents with five reviewed for accidents. Based on interviews, observations, and record review, the facility failed to ensure a safe care environment related to the use of Resident (R)35's fall prevention interventions for his wheelchair. This deficient practice placed R35 at risk for preventable falls and injuries. Findings included: - The Diagnosis tab within R35's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) restlessness, agitation, major depressive disorder (major mood disorder), muscle spasms, muscle weakness, and repeated falls. R35's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS documented he required partial to moderate assistance with dressing, transfers, bed mobility, bathing, personal hygiene, and personal hygiene. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 58 residents. The facility identified one resident on 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). Based on record review, observations, and interviews, the facility failed to ensure the blood pressure cuff, pulse monitor, and oxygen saturation equipment were sanitized after each resident's use. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 12/16/24 at 07:47 AM, License Nurse (LN) I obtained a resident's blood pressure and pulse in the main dining room. LN I did not sanitize the pulse monitor or blood pressure cuff before or after resident use. On 12/17/24 at 07:18 AM, LN G obtained a resident's blood pressure, oxygen saturation, and pulse in the main dining room. LN G did not sanitize the blood pressure cuff, oxygen saturation monitor, or pulse monitor before or after resident use. On 12/18/24 at 07:42 AM, LN G obtained the resident's blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2024-12-18 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 58 residents. The sample included 15 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer and administer or obtain informed declinations for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial pneumonia infections) vaccination for Resident (R) 32 and R52. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R32's clinical record revealed the PCV13 was administered on 11/30/17, and the PSV23 was administered on 08/30/13. R31's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. Review of R53's clinical record revealed the PCV13 was administered on 09/27/18, and the PSV23 was administered on 09/02/19. R53's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-27 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserve nutritive value, flavor, and appearance for nine residents who received pureed diets placing the residents at risk for inadequate nutrition. Findings included: - On 06/22/23 at 08:35 AM, observation revealed Dietary Staff (DS) CC prepare pureed meal for nine residents. DS CC placed nine plus servings of refrigerated meatloaf into a blender, then added milk from a gallon jug, blending the mixture until desired consistency. DS CC placed the blended meat into serving pans placing additional milk on top of the mixture before placing in the oven for heating. On 06/26/23 at 02:16 PM DS BB stated DS CC should have used beef broth to puree the meat. DS BB stated the facility was getting used to using the recipes obtained recently from a consulting diet source. The pureed meat recipe instructions directed to combine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to report to the state agency Resident (R)16's injuries of unknown origin and failed to report to the state agency R14's unwitnessed fall resulting in fracture. This placed the residents at risk for unidentified and ongoing abuse or neglect. Findings included: - The Electronic Medical Record (EMR) for R16 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and edema (swelling). The Annual Minimum Data Set (MDS), dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting and extensive assistance of one staff for dressing, eating and personal hygiene. The MDS further documented R16 had no skin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 had a census of 66 residents. The sample included 18 residents, with one reviewed for post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for PTSD for one sampled resident, Resident (R) 36, to provide direction to staff to ensure R36 received care to eliminate or mitigate triggers that may cause re-traumatization of the resident. This placed the resident at risk for unmet needs. Findings included: - The Electronic Medical Record (EMR) for R36 documented diagnoses of PTSD, dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (a disruption of blood flow to the brain due to problems with the blood vessels that supply it), and major depression (abnormal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-27 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents of which 18 were reviewed for care planning. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent falls for Resident (R) 14, 57, and 21. This deficient practice placed the residents at risk for injuries to uncommunicated care needs. Findings included: - The Medical Diagnosis section in R14's Electronic Medical Record (EMR) included diagnoses of dorsalgia (back pain), scoliosis (curvature of the spine), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, fatigue, kyphosis (outward curvature of the spine), cervicalgia (neck pain), fracture of left clavicle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 66 residents. The sample included 18 residents. Based on observation, record review and interview the facility failed to prevent medication administration errors for Resident (R) 10's when staff crushed and mixed the medications and placed them in R10's food. The services the facility provided R10 did not meet professional standards of quality. This deficient practice placed R10 at risk for adverse reactions by not receiving the appropriate amount of medications prescribed. Findings included: - R10's Electronic Medical Record (EMR), documented diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs), and anxiety disorder (mental health disorder with feelings of worry, anxiety, or fear that interferes with daily activities). The Quarterly Minimum Date Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 66 residents. The sample included 18 residents with one reviewed for discharge. Based on record review and interview, the facility failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay for Resident (R)67. This placed the resident at risk for unmet care needs. Findings included: - R67's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), dated [DATE], documented R67 had intact cognition, delusions, and no behavioral symptoms. The MDS further documented R67 required supervision with activities of daily living, had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag), received an antidepressant (class of medications used to treat mood disorders) and an antibiotic (medication to treat infections), had no therapy services and did not have an active…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents, with two reviewed for skin conditions not pressure related. Based on observation, record review, and interview, the facility failed to implement interventions to prevent skin tears for one sampled resident, Resident (R) 16, and the facility failed to protect skin to prevent bruises during a transfer for R65. This placed the residents at risk for further injury. Findings included: - The Electronic Medical Record (EMR) for R16 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and edema (swelling). The Annual Minimum Data Set (MDS), dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting and extensive assistance of one staff for dressing, eating and personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 66 residents. The sample included 18 residents with two being reviewed for bowel/bladder incontinence, indwelling catheter (tube placed in the bladder to drain urine into a collection bag), and urinary tract infections (UTI). Based on observation, record review and interviews, the facility failed to provide Resident (R) 35 with sanitary catheter care while draining the urine drainage bag which placed R35 for risk of infection and cathter related complications. Findings included: -The Medical Diagnosis section within R35's Electronic Medical Record (EMR) included diagnoses of mild cognitive impairment, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, benign prostatic hyperplasia (BPH-age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms, mechanical complication of other urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 66 residents. The sample included 18 residents, with one reviewed for post -traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 36 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed the resident at risk for unmet behavioral health care needs. Findings included: - The Electronic Medical Record (EMR) for R36 documented diagnoses of PTSD, dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (a disruption of blood flow to the brain due to problems with the blood vessels that supply it), and major depression (abnormal emotional state characterized by exaggerated feelings of sadness,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents, with five reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interview, the facility failed to provide the necessary treatment and services to attain or maintain the highest practicable physical and psychosocial well-being for Resident (R) 21, who had dementia and related behaviors. This placed the resident at risk for decreased quality of life. Findings included: - The Electronic Medical Record (EMR) for R21 recorded diagnoses of dementia, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), other symptoms and signs involving cognitive functions and awareness, and Alzheimer's disease (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R21 had severely impaired cognition and required extensive assistance of two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-27 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents, with six reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Pharmacy Consultant addressed the facility's lack of assessing and monitoring behaviors and side effects for Resident (R) 60's use of Haldol (antipsychotic medication class used to treat major mental disorder characterized by a gross impairment in reality and other mental emotional conditions). This deficient practice placed the resident at risk for unnecessary psychotropic (alters mood or thought) medication. Findings included: - R60's Electronic Health Record (EHR) documented diagnoses of schizophrenia (a psychiatric disorder that affects a person's ability to think, feel, and behave clearly). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS documented the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents, with six reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to assess and monitor behaviors and side effects related to Resident (R) 60's use of Haldol (antipsychotic medication class used to treat major mental disorder characterized by a gross impairment in reality and other mental emotional conditions). This deficient practice placed the resident at risk for unnecessary psychotropic (alters mood or thought) medication. Findings included: - R60's Electronic Health Record (EHR) documented diagnoses of schizophrenia (a psychiatric disorder that affects a person's ability to think, feel, and behave clearly). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS documented the resident received antipsychotic medication on a routine basis, and had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review and interview the facility failed to prevent medication administration errors for Resident (R) 10 when staff crushed and mixed his medications and placed them in R10's food. This deficient practice placed R10 at risk for adverse reactions by not receiving the appropriate amount of medications prescribed. Findings included: - R10's Electronic Medical Record (EMR), documented diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs), and anxiety disorder (mental health disorder with feelings of worry, anxiety, or fear that interferes with daily activities). The Quarterly Minimum Date Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven indicating severely impaired cognition. The MDS documented R10 required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-12-02 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 65 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to employ a full time certified dietary manager for 43 residents who resided in the facility and received meals from the facility kitchen. Findings included: - On 11/29/21 at 10:00 AM, observation revealed Dietary Staff (DS) BB and DS CC serving food and preparing lunch for the residents. On 11/29/21 at 10:00 AM, DS BB and DS CC stated they were co-managers of dietary for the facility and verified neither was certified by the state as a certified dietary manager. On 12/02/21 at 03:30 PM, Administrative Staff A verified the facility should have a certified dietary manager. The facility's Dietary Manager Certification policy, dated January 2021, documented the facility required the dietary manager to be a full time employee and have either a Registered Dietician license or a Dietary Certification by the state of Kansas. The facility failed to employ a full time certified dietary manager for the 64 residents who resided in the facility and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-12-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 had a census of 65 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in the facility kitchen under sanitary conditions. Findings included: - On 11/29/21 at 10:00 AM, observation in the facility kitchen revealed one large air unit above a food preparation area had blackish and gray substances on the air vents and the filter was full of blackish substance, with a small amount hanging down. Further observation revealed peeling ceiling paint around the air unit and a two-foot-long area of peeling paint over the bakery preparation area with an approximately 4-inch x 8-inch strip hanging down. The Kitchen Cleaning Schedule documented the last staff entry dated 11/08/21. Review of the facility maintenance requests for the month of November 2021 revealed no requests for cleaning the vent in the kitchen or fixing the peeling paint. On 11/29/21 at 10:00 AM, Dietary Staff CC verified the dirty air vent and peeling paint areas in the kitchen and verified the last initialed entry 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.
- Potential for harm · D2021-12-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 65 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 6's, and R35's insulin (hormone which allows cells throughout the body to uptake glucose) pens with the date opened, expiration date and resident name in two of four medication carts. Findings included: - On 11/29/21 at 09:55 AM, observation of the North [NAME] medication cart, revealed R6's Humalog (a fast acting insulin that starts working faster and works for a shorter period of time than regular insulin) flex pen lacked a date opened, date of expiration, and resident name. On 11/29/21 at 10:10 AM, observation of the South East medication cart, revealed R35's Levemir (a long acting insulin that can work for around 24 hours or longer) flex pen lacked a date opened, date of expiration, and resident name. On 11/29/21 at 09:55 PM, Licensed Nurse (LN) G verified R6 received insulin daily, and the insulin flex pen lacked a date opened, a date of expiration, and/or a resident's name. On 11/29/21 at 10:10 AM, LN H…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 65 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to prevent the development and transmission of infection when staff failed to properly store Resident (R)29 and R30's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help). Findings included: - On 12/01/21 at 11:25 AM, observation revealed R29 and R30's oxygen tubing and nasal cannula, coiled up, unbagged, and placed under the handle of the oxygen concentrator in the East dining room. On 12/02/21 at 11:00 AM, observation revealed R29 and R30's oxygen tubing and nasal cannula coiled up, unbagged, and placed under the handle of the oxygen concentrator in the East dining room. On 12/02/21 at 11:10 AM, Administrative Nurse H stated R29 and R30 used their oxygen continuously and the facility had enough concentrators to place one in the resident's room and another concentrator was left in the dining room for the resident's use. Administrative Nurse H stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$13,397 in federal fines across 1 penalty.
- $13,397 — penalty dated 2024-06-10
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
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| EDELMAN, STEVEN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2023 |
| EISENBISE, DAVID | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2017 |
| KAEB, JASON | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| MENOLD, DAYTON | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 01/01/2020 |
| ABERLE, RICK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/04/2023 |
| ALLEN, RACHEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| PAINTER, DEBRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/24/2011 |
| WENGER, JEAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2022 |
CMS files one row per role, so the 15 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175376. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-18, 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.