Wellsville Manor
304 W 7th St, Wellsville, KS 66092 · For profit - Corporation · 51 certified beds · (785) 883-4101 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 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 | 19.1% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.0% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.5% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.7% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.7% | 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 | 3.3% | 4.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 17.6% | 16.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 4.1% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 4.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 20.0% | 22.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.6% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.5% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 31.0% | 73.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.5% | 22.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.2% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.13 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.27 | 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.
55.2% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 24.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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 | 55.2%CMS range 44.9–64.0 | 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 | 9.9%CMS range 6.8–13.7 | 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 | 24.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 40.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 40.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 3.9–14.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 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 51 beds and averages 50.4 residents a day — about 99% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
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 4.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.91 is at or above 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 4.24 hrs/resident/day on weekends vs 4.91 on weekdays — 14% thinner on weekends. RN hours go from 0.76 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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 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.
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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · F2026-05-21 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to provide the services of a full-time Certified Dietary Manager (CDM) for the residents who resided in the facility and received their meals from the kitchen. Findings included: - On 05/20/26 at 11:00 AM, Dietary Staff BB verified she was the Certified Dietary Manager (CDM) for the two facility kitchens but continued to work at another facility as well.During an interview on 05/21/26 at 09:35 AM, Administrative Staff A stated there should be a full-time CDM on site, and this was the expected transition for Dietary Staff BB. Administrative Staff A verified there should be a qualified dietician or other clinically qualified nutrition professional working full-time in the facility, to oversee the kitchen staff and dietary needs of the residents.During an interview on 05/21/26 at 11:05 AM, Consultant GG verified she was overseeing seven facilities kitchens and currently visits this facility on Fridays, then verified that neither she nor the CDM are working over 35 hours a week at the current facility.
- Potential for harm · Fcited before2026-05-21 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to ensure effective sanitizing of dishes when the sanitizer did not reach 120 degrees Fahrenheit, in one of the facility's two kitchens. Findings included:- During an observation on 05/20/26 at 12:15 PM, Dietary Staff EE ran a cycle of glassware through the sanitizer, in the secondary kitchen, and verified the temperature was 111 degrees Fahrenheit (F). During an interview on 05/20/26 at 12:30 PM, Maintenance Staff U confirmed the temperature on the sanitizer should be 120 degrees F. On 05/20/26 at 03:00 PM, Maintenance Staff U stated the temperature on the sanitizer was adjusted to 120 degrees Fahrenheit. The facility's undated Dietary Services Leadership & Shared CDM Policy stated residents are to receive safe, sanitary, and nutritionally adequate meals in accordance with physician orders, resident preferences and regulatory requirements.
- Potential for harm · F2026-05-21 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement adequate infection control practices when staff failed to perform hand hygiene and failed to sanitize shared equipment. Findings included:- On 05/20/2026 at 01:25 PM, an observation revealed Certified Nurse Aide (CNA) P and CNA N used a Hoyer lift (full body mechanical lift) for Resident (R) 35 who was 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) and transferred the resident from the wheelchair to the bed to change the resident's soiled brief. CNA P and CNA N washed their hands and applied personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses before transferring and changing resident). CNA P and CNA N removed the soiled brief and applied a clean brief without changing gloves and performing hand hygiene. The two CNA staff then removed their PPE and placed it in the trash.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 · D2026-05-21 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to inform Resident (R) 5 or her representative about the risk and benefits of taking an antidepressant (a class of medications used to treat mood disorders).Findings included:- R5's Electronic Medical Record (EMR) revealed the following diagnoses: major depressive disorder (major mood disorder that causes persistent feelings of sadness).R5's 06/10/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS recorded R5 took a diuretic (a medication to promote the formation and excretion of urine), opioid (a class of controlled drugs used to treat pain), hypoglycemic (a type of medication to treat high blood glucose levels), and an anticonvulsant.R5's Falls Care Area Assessment (CAA) documented R5 received pain medications and diabetic medications.R5's Psychotropic Drug Use CAA was not triggered.R5's Care Plan documented R5 took an antidepressant for a diagnosis of major depressive disorder to improve functioning and reduce symptoms 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 · D2026-05-21 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to accurately assess and monitor a psychotropic medication for Resident (R) 27, who received Ambien (a psychotropic medication used to induce sleep) nightly.Findings included:- R27's Electronic Medical Record (EMR) revealed the following diagnoses: insomnia (inability to sleep) and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R27's 09/08/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS recorded R27 took an antidepressant (a class of medications used to treat mood disorders), anticoagulant (a class of medications used to prevent the blood from clotting), and opioid (a class of controlled drugs used to treat pain). The MDS did not accurately document that R27 took a hypnotic (a class of medications used to induce sleep).R27's 09/08/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R27 took pain medication which managed her pain well but lacked documentation of 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 · D2026-05-21 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide Resident (R) 2, and R54 a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. The facility also failed to provide R2 or the representative with the bed-hold upon discharge to the hospital.Findings included: 1. R2's Electronic Medical Record (EMR) revealed a diagnosis of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) and urinary tract infection (UTI-an infection in any part of the urinary system).R2's Minimum Data Set (MDS) tab documented a Discharge MDS on 11/20/25, 01/23/26, 03/14/26, and 04/26/26.R2's Nurse's Note, dated 11/21/25 at 01:50 AM, documented R2 returned to the facility after having the nephrostomy tubes changed, at 09:10 PM, R2 had a temperature of 102 Fahrenheit (F), and was sweating and had low back pain. The doctor was notified and advised staff that R2 likely required evaluation at the hospital 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 · D2026-05-21 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to accurately assess Resident (R) 5 and R27.Findings included:1. R5's Electronic Medical Record (EMR) revealed the following diagnoses: major depressive disorder (major mood disorder that causes persistent feelings of sadness).R5's 06/10/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS recorded R5 took a diuretic (a medication to promote the formation and excretion of urine), opioid (a class of controlled drugs used to treat pain), hypoglycemic (a type of medication to treat high blood glucose levels), and an anticonvulsant. The MDS did not accurately document that R5 took an antidepressant (a class of medications used to treat mood disorders).R5's 06/10/25 Falls Care Area Assessment (CAA) documented R5 received pain medications and diabetic medications.R5's 06/10/25 Psychotropic Drug Use CAA was not triggered due to not being accurately assessed on the MDS.R5's Care Plan documented R5 took an antidepressant for a diagnosis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-21 · 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
Based on observation, interview, and record review the facility failed to identify and implement resident-centered interventions and monitor effectiveness of interventions to prevent falls for Resident (R) 3 who was at high risk for falls. Findings included:- R3's Electronic Health Record (EHR) documented diagnoses of pneumonitis (an infection in the lungs due to inhalation of food and vomit), sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), polyosteoarthritis (degenerative changes to many joints characterized by swelling and pain), encephalopathy (a broad term for any brain disease that alters brain function or structure), dementia (a progressive mental disorder characterized by failing memory and confusion), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), urinary tract infection (UTI-an infection in any part of the urinary system), overactive bladder (a sudden, uncontrollable urge to urinate that is difficult to postpone), and diarrhea.R3's Annual Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · 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
Based on interview and record review, the facility failed to ensure that Resident (R) 2 received appropriate treatment and services to prevent urinary tract infections to the extent possible by failing to keep the urine collection bag attached to the nephrostomy(an artificial opening created between the kidney and the skin which allows for the urinary diversion) tubes below the level of the kidney.Findings included:- R2's Electronic Medical Record (EMR) revealed a diagnosis of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) urinary tract infection (UTI-an infection in any part of the urinary system), and a kidney infection.R2's 07/06/25 admission Minimum Data Set (MDS) documented R2 had an indwelling catheter and took antibiotics.R2's 07/06/25 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R2 was in isolation for a UTI and had nephrostomy tubes in both kidneys, which staff are managing.R2's EMR contained Discharge Instructions for Nephrostomy Tube Care, 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 · Fcited before2024-08-21 · 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 reported a census of 43 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 08/20/24 at 07:41 AM, the following areas of concern were noted: 1. The trash can in the dish washing area contained dried-on food and liquid substances on all sides and the lid. 2. The trash can by the hand washing sink contained dried-on food and liquid substances on all sides and the lid. 3. The shelf underneath a preparation table which held plastic pitchers, cutting boards and clean eating utensils, contained food debris. 4. The inside of the microwave contained dried-on food on all sides and the top. 5. Four colored cutting boards contained deep grooves and were discolored. 6. An oscillating fan had a build-up of dust in the slats of the fan. 7. One side of the stove had dried-on food substances. 8. One of two reach-in freezers had a build-up of food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · E2024-08-21 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents with 14 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate assessment/Minimum Data Set (MDS for four residents (R)23, R 37, R 2, and R 13 related to siderails used as restraints. Findings included: - Review of Resident (R)23's undated Physician Orders documented diagnoses which included hypertension (high blood pressure), chronic kidney disease, and heart failure. The admission Minimum Data Set (MDS) dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. The MDS indicated bedrails not used as restraints (physical restraint are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). The Quarterly MDS dated 04/04/24, documented BIMS score of 15, indicating…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-21 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents with 14 sampled for review. Based on observation, interview, and record review, the facility failed to complete a Significant Change Minimum Data Set (MDS), within 14-days, as required, for two Residents (R)19 and R 44, regarding admission on to hospice care. Findings included: - Review of Resident (R)19 electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score to be four, indicating severe cognitive impairment. The resident did not have a condition or chronic disease which would result in a life expectancy of less than six months, and she did not receive hospice care during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/26/24, documented the resident had a diagnosis of dementia. The Quarterly MDS, dated 08/06/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents with 14 sampled for review. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one Resident (R)19, regarding admission on to hospice care. Findings included: - Review of Resident (R)19 electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score to be four, indicating severe cognitive impairment. The resident did not have a condition or chronic disease which would result in a life expectancy of less than six months, and she did not receive hospice care during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/26/24, documented the resident had a diagnosis of dementia. The Quarterly MDS, dated 08/06/24, documented the staff assessment for cognition revealed…
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 before2024-08-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 resident with 14 residents selected for review, which included two residents reviewed for respiratory needs. Based on observation, interview, and record review, the facility failed to provide appropriate nebulizer equipment for one of the two Residents (R)2. Findings included: - Review of Resident (R) 2's medical record revealed diagnoses that included femur (long bone in the thigh) fracture and chronic obstructive pulmonary disease (COPD progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive status. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/08/24, assessed the resident with COPD and slept with the head of the bed elevated due to shortness of breath when lying flat. The Care Plan…
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 before2022-11-30 · 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 reported a census of 48 residents. Based on observation, interview and record review, the facility failed to store, prepare, and serve food in a sanitary manner for the residents of the facility. Findings included: - Observation, on 11/28/22 at 08:44 AM, revealed the following areas of concern in the refrigerators in the main kitchen: 1) Five condiment squeeze bottles without caps over the open tips. 2) Three sausage patties in a baggie dated 11/21/22. 3) Biscuit gravy in a plastic container dated 11/23/22. 4) An opened bag of bacon bits dated 11/12/22. 5) Sliced black olives in a plastic bag dated 11/15/22. 6) Two ice packs for resident treatments. 7) A resident's personal bowl of turkey and mashed potatoes covered with plastic wrap dated 11/25/22. The pantry contained the following areas of concern: 1) No open date or expiration date on a bag of crushed cornflakes. 2) An opened and unsealed bag of flour. 3) A box of bread dated 11/18/22, with no date on the individual loaves of bread. 4) Raisin Bran in a plastic cereal container dated 07/22. 5) [NAME] crisp cereal in…
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 · E2022-11-30 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 48 residents and identified four residents on physician ordered pureed diets. Based on observation, interview and record review, the facility failed to ensure staff prepared the pureed (a process to render foods to a consistency of pudding or mashed potatoes) foods in a manner to provide nutritional support as planned in the recipes and menus. Findings included: - Interview, on 11/28/22 at 08:44 AM, with Dietary Staff BB, revealed four residents received pureed foods. Review of the Diet Spreadsheet for Wednesday (11/29/22) for pureed diet lunch, revealed the following for the planned pureed consistency meal: grilled chicken, oven roasted rosemary potatoes, California blend vegetables, chef's choice of dessert, and buttered dinner roll. Review of the recipe for pureed foods for five servings of the pureed oven roasted rosemary potatoes, instructed staff to measure 2.5 cups of potatoes and add 0.5 cup of hot milk gradually to blend until smooth consistency. The recipe indicated that the liquid specified in the recipe was a suggested amount. Review 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 before2022-11-30 · 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 reported a census of 48 residents and identified three as confused and self-mobile. The facility failed to keep hazardous chemicals out of the reach of the identified three confused self- mobile residents to prevent incidental ingestion and accidents. Findings included: - Observation on 11/30/22 at 07:50 AM, revealed an unlocked whirlpool/shower room door on the Meadowlark area. An unlocked cabinet next to the whirlpool contained a gallon bottle of 12% bleach. The bottle label documented, Keep out of the reach of children. On 11/30/22 at 07:55 AM, Licensed Nurse G verified the door to the whirlpool/shower room was to be locked at all times. Observation on 11/30/22 at 08:00 AM, revealed an unlocked whirlpool/shower room door on the Countryview area. A spray bottle containing Pro-con turquoise 3 cleaner disinfectant sat out directly available on a sink countertop. The bottle had a label that documented, Keep out of the reach of children. On 11/30/22 at 08:15 AM, housekeeping employee U verified the doors to the whirlpool/shower door in the Meadowlark area were to always…
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 before2022-11-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 48 residents with 13 residents sampled, including two residents reviewed for respiratory. Based on interview, record review and observation, the facility failed to ensure sanitary use of respiratory equipment to prevent respiratory infections for one of the two sampled residents, Resident (R)4, regarding storage of distilled water for the oxygen (O2) concentrator. Findings included: - Review of Resident (R)4's electronic medical record (EMR) included the following diagnoses: Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), lung cancer (cancer of the lung) and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She had a diagnoses of cancer, Chronic…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| AVERILL, SCOTT | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | since 01/01/2018 |
| HOBACK, DENISE | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; ADP OF THE SNF | since 01/01/2018 |
| LEE, TARA | Individual | W-2 MANAGING EMPLOYEE | since 01/01/2024 |
| MCCOY, JILLIAN | Individual | W-2 MANAGING EMPLOYEE | since 01/01/2018 |
| JOYA LIVING & HEALTHCARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2018 |
CMS files one row per role, so the 8 rows in the source record cover these 5 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.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $624K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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 175250. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, 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.