Good Samaritan - Wamego
2011 Grandview Drive, Wamego, KS 66547 · Non profit - Corporation · 45 certified beds · (785) 456-9482 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
- 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $26,525 in federal fines (most recent 2024-05-16)
- its payroll-based staffing score sits well above its independent inspection score
- its facility-reported quality-measure rating is low (2/5)
- about 17% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
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 | 11.5% | 17.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.5% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.4% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.8% | 2.9% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.7% | 6.5% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.3% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 19.9% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 44.9% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.6% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.5% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 13.1% | 22.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.2% | 18.1% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.02 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 5.23 | 2.13 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 45 beds and averages 43.3 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.97 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 3.23 hrs/resident/day on weekends vs 3.91 on weekdays — 17% thinner on weekends. RN hours go from 1.07 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 21% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility identified a census of 39 residents with three residents reviewed for elopement. Based on record review, observation, and interview, the facility failed to ensure staff provided adequate supervision to cognitively impaired Resident (R) 1, who had a history of wandering and elopement, to prevent R1 from exiting the facility unsupervised through an unlocked kitchen area and door. On 05/04/24 at approximately 05:58 PM R1 sat in the dining room finishing his supper. The only Certified Nurse Aide (CNA) in the dining room assisted another resident out of the dining room. R1 then got up from his table and, with his walker, walked to the dishwasher room. R1 attempted to open the door but it was locked. R1 left his walker at that doorway and walked back towards the front of the dining room. R1 walked to the next doorway, which was open and permitted R1 to enter the kitchen. R1 walked through the facility kitchen and went out the back door of the kitchen at 06:02 PM. The regular alarm sounded and Licensed Nurse (LN) G checked the alarm system that was going off. The alarm 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.
- Actual harm · G2022-08-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 43 residents. The sample included 14 residents, with three reviewed for nutrition. Based on observation, record review, and interview the facility failed to provide the correct physician ordered nutritional supplement for Resident (R)34, who had a significant unplanned weight loss. The facility failed to notify the Registered Dietician and/or physician when R34 continued to decline an ordered nutritional supplement. The facility further failed to identify and implement additional interventions to prevent weight loss, which included the resident's preferred meals and snacks and failed to attempt to fortify routinely consumed food items. These deficient practices placed R34, who had a significant loss of 15.54 percent in 30 days at continued risk for unintentional weight loss, malnutrition, and related complications. Findings included: -The Medical Diagnosis section within R34's Electronic Medical Record (EMR) included diagnoses of chronic pain syndrome, hypertension (elevated 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.
- Potential for harm · Fcited before2024-02-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and service food in a sanitary manner for the residents who reside in the facility and receive meals from the facility kitchen which placed the residents at risk for foodborne illness. Findings included: -On 01/30/24 at 08:32 AM, during the initial tour of the facility's kitchen, observation revealed the walk-in refrigerator stored a five-pound open, unsealed, undated roll of meat on the eye level shelf. On the shelf directly under the open unsealed meat roll were four small bowls of chopped lettuce and four cream-type pie slices which were not covered or labeled. Further into the walk-in refrigerator was an open, undated, unsealed bag of chopped lettuce, celery stocks, and hash brown type of potato patties. The walk-in freezer contained three plastic-wrapped waffles and an open unsealed box of chicken strips that lacked open dates. Upon further observation, Dietary Staff (DS) BB prepared over-easy cooked eggs 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.
- Potential for harm · Dcited before2024-02-05 · 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 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with trauma triggers and coping strategies for Resident (R)19 and failed to address sexual behaviors for R3. The placed R19 and R3 at risk for impaired care due to uncommunicated care needs. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of pain, malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of left female breast, degenerative disease of nervous system, repeated falls, generalized anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings pf sadness), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung…
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 · D2024-02-05 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 41 residents. The sample included 12 residents, with one reviewed for discharge. Based on interview and record review, the facility failed to develop a discharge plan for one sampled resident, Resident (R) 40, who discharged to home with family. This placed the resident at risk for unidentified discharge goals and impaired discharge planning. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), encephalopathy (a broad term for any brain disease that alters brain function or structure), hypertension (high blood pressure), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion), and weakness. The EMR lacked evidence a discharge care plan had been developed upon admission to the facility. The Nurse's Note, dated 11/03/23 at 11:40 AM, documented R40 was admitted to the facility after hospitalization for sepsis and planned to return home…
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 · D2024-02-05 · 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
The facility had a census of 41 residents. The sample included 12 residents. 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 and post-discharge plan for Resident (R)40. This placed the resident at risk for impaired care and services. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), encephalopathy (a broad term for any brain disease that alters brain function or structure), hypertension (high blood pressure), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion), and weakness. The EMR lacked evidence a discharge care plan had been developed upon admission to the facility. The Nurse's Note, dated 11/03/23 at 11:40 AM, documented R40 was admitted to the facility after hospitalization…
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 · D2024-02-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide cueing or assistance with eating for Resident (R) 17 who had weight loss. This placed the resident at risk of continued weight loss and unmet care needs. Findings included: - R17's Electronic Medical Record (EMR) documented diagnoses of pain, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), essential tremor, gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, dementia (progressive mental disorder characterized by failing memory, confusion), heart disease, and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had severe cognitive impairment, delusions (untrue persistent belief or perception held by a person although…
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 before2024-02-05 · 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 41 residents. The sample included 12 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 22's personal alarm system was monitored as ordered to prevent elopement (when a cognitively impaired resident leaves the facility without staff knowledge or supervision). This placed the resident at risk for preventable accidents. Findings included: - The Electronic Medical Record (EMR) for R22 documented diagnoses of weakness, unsteadiness on feet, hypertension (high blood pressure), cognitive-communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), and disorientation (having lost one's self of direction). The admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition and required extensive assistance from one staff for dressing and toileting, and limited assistance from one staff for bed mobility, transfers, ambulation, 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 · D2024-02-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 19 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed R19 at risk for impaired quality of life. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of pain, malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of left female breast, degenerative disease of nervous system, repeated falls, generalized anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings pf sadness), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty…
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 · D2024-02-05 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility has a census of 41 residents. The sample included 12 residents, with eight residents reviewed for behaviors. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 3 for sexual behaviors and failed to provide supervision for R11, who had resident-to-resident altercations. This placed the residents at risk for decreased quality of life. Findings Include: - The Electronic Medical Record (EMR) documented R3 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling caused due to excess fluid accumulation in the body tissues), pain, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and was independent with all activities of daily living (ADL), had no behaviors, and received antianxiety (class of medications that calm and relax people) and antidepressant (class of medications used to treat mood disorders)…
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 before2024-02-05 · 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 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported that Resident (R) 8 lacked a 14-day stop date or specified duration with physician rationale for as-needed (PRN) psychotropic (alters mood or thought) medication and R3 lacked evidence of blood sugar checks and insulin administration as ordered. This placed the residents at risk for inappropriate use of medications. Findings included: - R8's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) without residual deficit, chronic kidney disease, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), generalized anxiety…
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 before2024-02-05 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to follow physician orders for Resident (3), who received insulin (controls the amount of sugar in the blood by moving into the cells), and failed to monitor R3's blood sugar as ordered. This placed the resident at risk for physical decline. Findings included: - The Electronic Medical Record (EMR) documented R3 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough made, or the body cannot respond to the insulin) type 2, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), edema (swelling caused due to excess fluid accumulation in the body tissues), pain, and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and was independent with all activities of daily living (ADL)…
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 15 citations
- Potential for harm · Dcited before2024-02-05 · 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 41 residents. The sample included 12 residents of which six were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 8 had a stop date for the use of as-needed (PRN) lorazepam (antianxiety-class of medications that calm and relax people), R9 had an approved indication or the required documentation for the use of Seroquel (antipsychotic- class of medications used to treat major mental conditions which cause a break from reality), and R19 had complete behavior documentation related the use of three psychotropic (alters mood or thought) medications. This placed the residents at risk of receiving unnecessary psychotropic medications. Findings included: - R8's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) without residual…
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 before2022-08-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 43 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to identify causative factors and implement resident-centered interventions to prevent falls for Resident (R) 30 and R14 who had falls which resulted in fractures, and R2, R36, R40 , and R42 who had multiple falls. Findings included: - The Medical Diagnosis section within R30's Electronic Medical Record (EMR) included diagnoses of history of falling, emphysema (long-term, progressive disease of the lungs characterized by shortness of breath), age-related physical debility, wedge compression fracture of second lumbar vertebra, history of transient ischemic attack (TIA-mini stroke), muscle weakness, pain, difficulty in walking, macular degeneration (progressive deterioration of the retina) and legal blindness, nondisplaced fracture of greater trochanter of left femur (thigh bone) and depression (abnormal emotional state characterized by exaggerated feelings 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 · Dcited before2022-08-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 43 residents. The sample included 14 residents, with eight reviewed for falls. Based on observation, record review, and interview, the facility failed to update interventions on the care plan to prevent falls for Resident (R) R2, and R30. This deficient practice placed the residents at increased risk for fall related injuries due to uncommunicated care needs. Findings included: -The Medical Diagnosis section within R2's Electronic Medical Record (EMR) included diagnoses of pain, urinary tract infection, depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic nephropathy (weakness, numbness,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-10 · tag F0697 — failed to manage pain — isolatedProvide 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 had a census of 43 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to appropriately treat Resident (R) 8's pain following a fall which resulted in a fractured right hip. This placed R8 at increased risk for unresolved pain and impaired comfort. Findings included: - R8's Medical Diagnosis section of the Electronic Medical Record (EMR) included diagnoses of altered mental status, Alzheimer's (progressive mental deterioration characterized by confusion and memory failure )disease, acute kidney failure, restlessness and agitation, muscle weakness, difficulty in walking, and unsteady on feet. The admission Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment, required extensive assistance of one to two staff for activities of daily living, was not steady, and only able to stabilize with human assistance with balance and transition. He had no functional range of impairment or therapy services. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 43 residents. The sample included 14 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify Resident (R) 42's PRN (as needed) alprazalom (a sedative used to treat anxiety) did not have a stop date, and failed to identify an inappropriate diagnosis for R2's Seroquel (antipsychotic medication), placing the resident at risk for unnecessary psychotropic (altering mood or thought) medications. Findings included: - The Electronic Medical Record (EMR) for R42 documented had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and difficulty walking (a change in normal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-10 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 43 residents. The sample included 14 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to obtain from the physician, blood sugar parameters for Resident (R) 10, who received insulin (injectable hormone used to control blood sugar levels). This placed R10 at risk for hyperglycemic (high blood sugar) or hyperglycemic (low blood sugar) episodes. Findings included: - The Electronic Medical Record (EMR) documented R10 had diagnoses of diabetes mellitus type 2 (when the body cannot use glucose, not enough made, or the body cannot respond to the insulin), hypertension (high blood pressure), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had intact cognition and was independent with all activities of daily living (ADL). The MDS further documented R10 received insulin, an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-10 · 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 43 residents. The sample included 14 residents, with five reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 42's as needed (PRN) alprazolam (a sedative used to treat anxiety) and failed to ensure an appropriate diagnosis for R2's Seroquel (antipsychotic medication). This placed the residents at risk for adverse side effects. Findings included: - The Electronic Medical Record (EMR) for R42 documented had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and difficulty walking. The admission Minimum Data Set (MDS), dated [DATE], documented R42 had severely impaired cognition 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 · F2021-06-02 · 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 had a census of 41 residents. Based on observation, record review, and interview, the facility failed to provide a certified dietary manager to carry out the functions of food and nutritional services for the 41 residents who resided in the facility and received meals from the facility kitchen. Findings included: - On 05/26/21 at 08:30 AM, observations revealed Dietary Staff (DS) BB participated and provided oversight of the breakfast meal preparation and service. On 05/26/21 at 08:30 AM, DS BB stated he was not certified but currently attended classes to become certified and was about half done with the classes. On 06/02/21 at 01:54 PM, Administrative Nurse D stated DS BB was not certified, was taking classes to become certified, and just started in the position a month ago. The facility's Organizational Structure Food and Nutrition Services policy, 03/08/21, documented the person who has overall responsibility for food and nutrition services at locations offering rehabilitation/skilled care services has the director of food and nutrition services job code to ensure…
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 before2021-06-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to prepare, store, and serve meals under sanitary conditions for the 41 residents who received meals from the facility kitchen. Findings included: - On 05/26/21 at 08:30 AM, observation during initial tour of the kitchen revealed the following: Parts Per Million (PPM) Sanitation Log missing documentation for two days in March, 15 days in April, and 25 days in May. The June PPM log had not been started as of 06/02/21 at 01:30 PM. Walk-in refrigerator/freezer Temperature Logs missing temperatures for two days in February, three days in April, and three days in May. Salad bar refrigerator Temperature Logs missing temperatures three days in February, one day in April, and 26 days in May. Dining room silver refrigerator Temperature Logs missing temperatures three days in February, and 12 days in May. On 06/02/21 at 01:54, Administrative Nurse D stated she understood how important it was for the temperature logs of the refrigerators to be completed to ensure the residents…
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 before2021-06-02 · 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 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to follow Resident (R) 3's toileting plan as care planned and failed to implement fall interventions for R7, who rolled out of bed twice. Findings included: - R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, required limited assistance of one staff for transfers, and frequently incontinent of bowel and bladder. The MDS documented the resident had two or more falls with minor injury, no functional impairment, and unsteady balance. The Fall Care Area Assessment (CAA), dated 02/17/21, documented the resident at risk for falls due to weakness, very poor safety awareness, severely impaired cognition, and often forgot to use her call light or walker. The CAA directed staff to monitor the resident for increased fall risk and reminders to use her walker and call light to reduce fall risk. The Fall Care Plan, 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.
- Potential for harm · D2021-06-02 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 12 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing and shaving services as care planned for one of two sampled residents, Resident (R) 17. Findings included: - R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, required extensive assistance of one staff for bathing, and supervision assistance of one staff for personal hygiene. The ADL Care Area Assessment, (CAA), dated 12/15/20, directed staff to monitor the resident's need for assistance and any other significant changes in ability to perform ADLs. The ADL Care Plan, dated 03/04/21, documented the resident requested bathing three times a week, directed staff to offer the resident a choice of a bath or shower, and assist the resident daily with shaving. The May 2021 Bathing Record documented the resident received a shower 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 · Dcited before2021-06-02 · 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 41 residents. The sample included 12 residents with six reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement interventions to prevent falls for two of six sampled residents, Resident (R) 3, when staff did not follow her toileting care plan and R7, who rolled out of bed twice. Findings included: - R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, required limited assistance of one staff for transfers, and two or more falls with minor injury. The MDS documented the resident frequently incontinent of bowel and bladder, no functional impairment, and unsteady balance. The Fall Care Area Assessment (CAA), dated 02/17/21, documented the resident at risk for falls due to weakness, very poor safety awareness, severely impaired cognition, and often forgot to use her call light or walker. The CAA directed staff to monitor the resident for increased fall risk and reminders 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.
- Potential for harm · Dcited before2021-06-02 · 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 41 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to identify medication concerns for two of five sampled residents, Resident (R) 10's blood pressures (BP) and pulses out of physician ordered parameters, identify an inappropriate diagnosis for R10's Seroquel (antipsychotic), and lack of physician's response to recommended gradual dose reduction for R10's Seroquel and R18's Sonata (hypnotic). Findings included: - R10's Physician Order Sheet (POS), dated 05/12/21, documented diagnoses of hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory, confusion), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R10's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score 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 · Dcited before2021-06-02 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to follow physician orders for administration of Ramipril (blood pressure medication) and Metoprolol Succinate (blood pressure medication), and failed to notify the physician for blood pressures and pulses out of the physician ordered parameters for one out of five resident, Resident (R)10. Findings included: - R10's Physician Order Sheet (POS), dated 05/12/21, documented diagnoses of hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory, confusion), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R10's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS recorded 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 before2021-06-02 · 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 41 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for Resident (R) 10's Seroquel (antipsychotic medication). Findings included: - R10's Physician Order Sheet (POS), dated 05/12/21, documented diagnoses of hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory, confusion), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R10's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS recorded the resident independent to requiring supervision of one staff for all activities of daily living, received antipsychotic medication on a routine basis, and a Gradual Dose Reduction (GDR) had not been attempted…
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
$26,525 in federal fines across 2 penalties.
- $9,315 — penalty dated 2024-05-16
- $17,210 — penalty dated 2024-03-27
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 GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.0 | +1.0 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 91 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 91; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANFORD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2019 |
| BROWN, GEORGE | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| DYKHOUSE, DANA | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| GASSEN, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/30/2024 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| HERSETH SANDLIN, STEPHANIE | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| MCCAUSLAND, MAUREEN | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| SCHIEFFER, KEVIN | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| SHULKIN, DAVID | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| WENZEL, THOMAS | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| FLUIT, JOEL | Individual | CORPORATE OFFICER | — | since 10/01/2022 |
| MIDDLETON, AIMEE | Individual | CORPORATE OFFICER | — | since 01/27/2022 |
| OLSON, NICHOLAS | Individual | CORPORATE OFFICER | — | since 04/08/2024 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER | — | since 01/01/2022 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2019 |
| BARBER, ANGELA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/14/2021 |
| MILNER, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/15/2018 |
| MORRISON, TONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
CMS files one row per role, so the 28 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
This home reported $747K paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175359. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-05, 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.