Lincoln Care And Rehab
4007 E Lincoln Street, Wichita, KS 67218 · For profit - Corporation · 45 certified beds · (316) 683-7588 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- 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 (43) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $40,104 in federal fines (most recent 2025-03-11)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 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 fell from 3 to 1 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 | 23.3% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.3% | 4.9% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.8% | 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 | 10.2% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.5% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 35.4% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.2% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 13.6% | 22.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.8% | 18.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | 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.
Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 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 35.1 residents a day — about 78% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.77 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.77 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 3.29 hrs/resident/day on weekends vs 3.97 on weekdays — 17% thinner on weekends. RN hours go from 0.85 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
43 citations, most serious first. The 12 most serious are shown; the remaining 31 are one tap away and print in full.
- Immediate jeopardy · J2025-03-11 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 39 residents with five residents sampled and one resident reviewed for served food in a form that met the resident's individual needs. Based on observation, interview, and record review, the facility failed to ensure staff provided cognitively impaired Resident (R) 2 with her prescribed mechanical soft diet (a modified diet that consists of soft, easy-to-chew foods that require minimal chewing) with ground meat texture, and instead served cut-up chicken to the resident, on her plate. R2 began to cough and choked on her food. The staff had to suction R2 when R2 could not clear her airway with coughing. The facility transferred R2 to the hospital later that evening. The hospital admitted R2 for fever, pneumonia, and dehydration. This deficient practice placed all residents at risk in immediate jeopardy. Findings Included: - Review of the Electronic Health Record (EHR) documented R2 had diagnoses of dysphagia (swallowing difficulty), and dementia (progressive mental disorder characterized by failing memory, confusion). The 12/08/24 Annual Minimum Data…
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.
- Immediate jeopardy · Jcited before2022-02-08 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 34 residents, with 12 residents included in the sample and one resident sampled for cardiopulmonary resuscitation (CPR, emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). The facility identified 26 residents with full code status, indicating the resident wishes for life saving measures to be utilized in emergent situations, to include CPR. Based on interview and record review, the facility staff failed to initiate CPR on a full-code Resident (R)86 on [DATE] at approximately 01:25 PM, when Licensed Nurse (LN) C and Certified Nurse Aide (CNA) D found the resident without respirations and pulseless. The staff thought the resident was a Do Not Resuscitate (DNR) due to the nursing report sheet did not list FULL beside R86's name to indicate the resident's full code status. Due to the lack of an effective code system in place to identify full code and DNR residents, staff failed to follow R86's wishes to be…
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 · F2025-05-15 · tag F0729 — widespreadVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 37 residents. Five Certified Nurse Aides (CNA) were reviewed for current certified nurse aide certifications. Based on interview and record review, the facility failed to ensure one CNA had a current and valid certificate. This placed the residents at risk for decreased quality of care. Findings included: - Review of CNA LL's files revealed CNA LL was hired on 05/16/22. CNA LL's file lacked evidence of a current certified nurse aide certificate. Review of CNA LL on the Nurse Aide Registry on 05/15/25 revealed CNA LL had an inactive CNA status as of 06/07/23. During an interview on 05/15/25 at 12:00 PM, Administrative Staff A reported he expected all the CNA staff to have a current certified nurse aide certificate. The facility did not provide a policy for the renewal of certified nurse aide certificate.
- Potential for harm · F2025-05-15 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 37 residents. Five Certified Nurse Aides (CNA) were reviewed for annual performance evaluations. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for CNA NN and CNA LL. This placed the residents at risk for decreased quality of care. Findings included: - Review of CNA NN's files revealed CNA NN was hired on 05/16/22. CNA NN's file lacked evidence a performance evaluation was done in the last 12 months. Review of CNA LL's files revealed CNA LL was hired on 02/29/20. CNA LL's file lacked evidence a performance evaluation was done in the last 12 months. During an interview on 05/15/25 at 12:00 PM, Administrative Staff A reported he expected all the can staff to have annual performance evaluations completed annually. The facility's Performance Management in the employee handbook dated 09/2024, documented the community believes that performance evaluations are a constructive means of improving the performance of both the employee and the community. An employee assessment is a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-15 · 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 37 residents. The facility had one main kitchen where dietary staff prepare all the food. Based on observation, interview and record review the facility failed to store food items in a sanitary manner when staff failed to date food items in the refrigerator and freezer. This placed the residents at risk of food-borne illness. Findings included: - Observation on 05/12/25 at 09:40 AM revealed one bag of beef patties were placed in the freezer without closure of the plastic bag. Further observation revealed two bags of chicken in a store bag sat on the floor in the refrigerator . The freezer floor had food debris visible. There were numerous bags of vegetables and sandwich meat which lacked a date received. In the kitchen there were nine loafs of bread found with expiration date of 02/22/25 and there was mold growing on the bread. Interviewed on 05/14/25 at 12:0 PM, Dietary Manager BB stated they expected the staff to make sure that all raw meat was on the bottom shelf, and that everything was dated with the open date and expiration date and when…
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 before2025-05-15 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 37 residents. Five Certified Nurse Aide (CNA) staff, who worked in the facility were reviewed for required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNAs with the required topics and no less than 12 hours per year. This placed the residents at risk for decreased quality of care. Findings included: - On 05/15/25 at 08:30 AM, review of training records for five CNAs revealed that CNA P, who was hired on 12/30/24 lacked dementia (progressive mental disorder characterized by failing memory, confusion) training. Review of CNA NN's employee file lacked evidence the CNA received dementia training and lacked the total number of in-service hours that were completed. During an interview on 05/15/25 at 12:00 PM, Administrative Staff A reported he expected the staff to have the required education and the required 12 hours annually. The facility's policy Staff Competency dated 06/2023 documented all nurse aides shall participate in regularly…
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 · E2025-05-15 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 37 residents, with 12 residents sampled. Based on interviews and record review, the facility failed to ensure residents received the opportunity to participate in the care planning process when staff failed to invite Residents (R) 31, R22, R4, R6, R32, and R1 or their responsible party to care plan meetings. The deficient practice placed the residents at risk for impaired resident rights and decreased autonomy. Findings included: - During an interview on 05/12/25 at 09:00 AM, R31 reported she did not know what a care plan meeting was and had never been invited. R31's Electronic Health Record (EHR) revealed the EHR lacked any documentation of a care plan meeting conducted in the past six months. During an interview on 05/12/25 at 09:14 AM, R22 reported he had not received any care plan invites. R22's EHR lacked documentation of a care plan meeting conducted in the past six months. During an interview on 05/12/25 at 10:17 AM, R4 reported she was not invited to care plan meetings. R4's EHR lacked any documentation of a care plan meeting conducted 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 · E2025-05-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings include: - During an observation on the initial tour of the facility at around 07:50 AM, several patches of white plaster spots were observed on several walls and doors of the hallway walls and entrance doors to the residents' rooms. There were several chipped floor tiles noted on the floors in the residents' hallway as well. During an observation on 05/12/25 at 08:51 AM, Resident (R) 5's bathroom floor had some holes in the flooring where the concrete floor could be seen through the holes. R5's grab bar next to the toilet had frayed worn duct tape on the handle. During an observation on 05/12/25 at 03:39 PM, R1's room had a vent cover off the ceiling that was supposed…
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 before2025-05-15 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 37 residents, with 12 residents sampled. Based on observation, interview, and record review, the facility failed to develop and implement a system to ensure the presence of at least one staff certified in cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) for residents who desired a Full Code status (full resuscitative measures). This deficient practice placed the residents at risk for decreased quality of care and inadequate resuscitative measures. Findings included: - Review of three current staff members' CPR certificates revealed Licensed Nurse (LN) PP had a current certification from an online CPR provider, named on the card, which did not have an instructor-led hands-on skills component. Review of the transportation schedule revealed that Certified Nurse Aide (CNA) AA transported Resident (R) 32, who was a Full Code status to and from his appointments three times a week from [DATE] through [DATE]. During 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 · Ecited before2025-05-15 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 37 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program related to the enhanced barrier precaution (EBP-a set of infection control measures that use goggles, gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing tube feeding care (a specialized medical flexible tube made of either silicone or plastic to deliver liquid nutrition directly int the stomach) or providing a shower to the resident with the tube feeding. Additionally, staff failed to disinfect the Hoyer lift (full body mechanical lift) after use and failed to utilize adequate hand hygiene. This placed the residents at risk for infections. Findings included: - Observation on 05/12/25 at 12:05 PM revealed Licensed Nurse (LN) K in R14's room reattaching the feeding tube the resident had pulled out. LN K did not utilize a gown during the care provided. Observation on 05/13/25 at 10:43 AM revealed Certified Nurse Aide (CNA) Q…
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 · D2025-05-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 37 residents, with 12 residents sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person cannot make their own decisions). Based on interview and record review, the facility failed to ensure one resident's advanced directives were thoroughly completed when Resident (R)7 had a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) which was only signed by a physician rendering it invalid. This placed the resident at risk for an impaired right to have advance directives honored. Findings included: - R7 's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) depression (excessive sadness), and anxiety. The 09/19/24 Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 required total dependence to complete…
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 · D2025-05-15 · 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
The facility reported a census of 37 residents with 12 residents sampled. Five residents were reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 7's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date or a specified duration which included the physician's rationale for extended use. This deficient practice placed the R7 at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications. Findings included: - R7 's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) depression (excessive sadness), and anxiety. The 09/19/24 Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 required total dependence to complete activities of daily living (ADL) including toileting, footwear, and personal hygiene. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 31 citations
- Potential for harm · D2025-05-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 37 residents. The sample included 12 residents with three residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 31, R32, and R1. This placed the residents at risk for impaired rights related to returning to the facility. Findings included: - R31's Electronic Health Record (EHR) documented R31 was transferred to the hospital on [DATE]. R31's EHR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R31 and/or her representative. R32's EHR documented R32 was transferred to the hospital on [DATE], [DATE], [DATE], and [DATE]. R32's EHR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R32 and/or his representative. R1's EHR documented R1 was transferred to the hospital on [DATE], [DATE], and [DATE]. R1's EHR…
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 before2025-05-15 · tag F0641 — isolatedEnsure 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 37. The sample included 12 residents. Based on interviews and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for Resident (R)22, R6 and R31. This placed the residents at risk for unidentified care needs and inadequate plan of care. Findings included: - R22's Electronic Medical Record (EMR) recorded a diagnosis dated 02/09/22 of obstructive sleep apnea (a sleep disorder characterized by periods without respirations). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Section O of the MDS lacked indication of the use of a continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep). The Quarterly MDS dated 03/27/25 under Section O lacked indication of use of the CPAP. The Physician Orders dated 07/15/23 documented R22 was to wear the CPAP at bedtime and during naps R22's…
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 · D2025-05-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 37. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to provide professional standards of care for Resident (R) 22 when staff failed to contact the physician for blood sugars greater than 400 milligrams (mg) per deciliter (dL) or lower than 60 mg/dL. This placed the resident at risk for impaired care and complications related to high or low blood sugar. Findings include: - R22's Electronic Medical Record (EMR) revealed a diagnosis dated 02/09/22 of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) The Annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted R22 received insulin (a medication used to treat high blood glucose)for seven days during the observation period. The Quarterly MDS 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 · D2025-05-15 · 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
The facility reported a census of 37 residents. The sample included 12 residents with one dependent resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide ADL care including grooming of facial hair in accordance with the resident's preferences for Resident (R) 2. This placed the resident at risk for impaired dignity and poor hygiene. Findings included: - R2's Electronic Health Record (EHR) revealed diagnoses of blindness of the right and left eye, paranoid schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and a need for assistance with personal care. The 06/20/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS recorded R2 had severely impaired vision and required no devices. The MDS noted R2 required moderate assistance for personal hygiene and maximal assistance for bathing. The 06/24/24…
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 · D2025-05-15 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 37 residents. The sample included 12 residents with one reviewed for visual services. Based on interview and record review, the facility failed to provide visual services or facilitate access to visual services for Resident (R) 31 who had impaired visual function. This placed the resident at risk for further deterioration of vision. Findings included: - R31's Electronic Health Record (EHR) revealed diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness) and cerebrovascular accident (CVA-stroke- 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). The 11/01/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 was dependent on staff for toileting activities of daily living (ADL). The MDS recorded R31 required maximal assistance with showering, lower body dressing, and transfers. The MDS recorded R31 required set-up…
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 before2025-05-15 · 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 37 residents. There were 12 residents in the sample including two residents reviewed for respiratory care. Based on observation, interviews and record review the facility failed to provide sanitary respiratory care and services when staff failed to clean the nebulizer (a device for administering inhaled medication) after each use for Resident (R) 14 and also failed to store the continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask in a sanitary manner for R22. This placed the residents at risk for infection and increased respiratory complications. Findings included: - R14's Electronic Medical Record (EMR) dated 08/11/22 revealed a diagnosis of pneumonia (inflammation of the lungs). The Significant Change Minimum Data Set dated 09/28/24 showed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate impaired cognition. The MDS noted R14 required substantial 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 · D2025-05-15 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 37 residents. The sample included 12 residents sampled with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, and confusion) care services. Based on observation, record review, and interviews, the facility failed to provide nonpharmacological dementia care and services to promote Resident (R) 7's highest practicable level of function and well-being. This placed the resident at risk for decreased quality of life. Findings included: - R7 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) depression (excessive sadness), and anxiety. The 09/19/24 Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 required total dependence to complete activities of daily living (ADL) including toileting, footwear, & personal hygiene. The MDS recorded…
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 before2025-05-15 · 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
The facility reported a census of 37 residents, with 12 residents sampled, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's monthly medication review (MRR) for Resident (R) 32. The deficient practice had the potential to lead to the residents receiving unnecessary medications. Findings included: - Review of the Electronic Health Record (EHR) for R32 included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), end-stage renal disease (ESRD-a terminal disease of the kidneys) and anxiety. The 07/24/24 Significant Change Minimum Data Set (MDS) documented R32 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R32 required maximal assist from staff for bathing, standing, and wheelchair mobility activities of daily living (ADL). The MDS recorded R32 required moderate assistance with toileting, transfer, and lower body dressing. The MDS recorded no…
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 · D2025-05-15 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
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 37 residents. The sample included 12 residents with one reviewed for dental services. Based on interview and record review, the facility failed to provide dental services or facilitate access to dental services for Resident (R) 31 who had widespread dental decay. This placed the resident at risk for further deterioration of dentition (of or having to do with teeth) and related complications. Findings included: - R31's Electronic Health Record (EHR) revealed diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness) and cerebrovascular accident (CVA-stroke- 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). The 11/01/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 was dependent on staff for toileting activities of daily living (ADL). 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 · D2025-03-11 · 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 39 residents with five residents sampled. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for Resident (R) 3's risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). This deficient practice placed the resident at risk for inadequate care and services. Findings included: - The Electronic Health Records (EHR) documented R3 had diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion) and depression. The 01/03/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. R3 had a total mood severity score of 00, indicating no depression and there were no behaviors documented on the assessment. R3 was independent with all his activities of daily living (ADLs). R3 wore a Wander Guard (bracelet that sets off an alarm…
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 before2025-03-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 39 residents with five residents sampled and one resident reviewed at risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on observation, interview, and record review the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)3, identified as a moderate risk for elopement. At approximately 11:28 AM on 02/22/25 R3 exited the facility when Certified Nurse Aide (CNA) L opened the exit door at the front entrance for another resident to enter into the facility. CNA L reported R3 quickly went out the door and she came back into the facility leaving R3 outside by himself, to inform the Licensed Nurse (LN) E. This deficient practice could potentially result in an injury. Findings included: - The Electronic Health Records (EHR) documented R3 had diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion) 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 · F2023-10-03 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to secure and provide appropriate storage of medications in the medication cart. Findings included: - On 09/28/23 at 03:32 PM, the facility medication cart, used to store all resident's medications, was not locked, and left unattended. On 09/28/23 at 03:35 PM, Certified Medication Aide (CMA) N confirmed she left the medication storage cart, which contained resident's medications, unlocked and unattended. On 09/28/23 at 03:35 PM, Administrative Nurse B confirmed the above findings and stated the medication cart which contained all resident's medications, should be secured when staff not in direct attendance, to ensure safe storage of resident's medications, and not left unlocked while unattended by the CMA. The facility policy, Storage of Medications F761, dated 10/2023, documentation included the facility shall store all drugs and biologicals in a secure manner. The facility failed to secure and provide appropriate storage of medications in the medication cart.
- Potential for harm · Fcited before2023-10-03 · 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
The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to maintain a sanitary environment to help prevent cross contamination and the spread of infections in the laundry, and to ensure appropriate handling, storage, processing, and transportation of linen for the residents of the facility. Findings Included: - The laundry tour on 10/03/23 at 09:10 AM, with laundry staff H, reported she did not use a gown, goggles/face shield when sorting soiled laundry. She reported she only used gloves when sorting soiled laundry. She reported she was not aware laundry staff should wear a gown and goggles/face shield when sorting contaminated soiled laundry to prevent cross contamination and the spread of infections. On 10/03/23 at 09:15 AM, Laundry Supervisor I, stated he was not aware laundry staff should wear gowns, goggles/face shields when sorting out contaminated soiled laundry. He reported he thought staff were to only to wear gloves when sorting contaminated soiled laundry to prevent cross contamination and the spread of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-03 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 44 residents. The facility identified four Certified Nurse Aides (CNAs) employed greater than one year. Based on interview and record review, the facility failed to develop, implement and permanently maintain an in-service training program for staff that is appropriate and effective to ensure the continuing competence of CNAs and appropriate care and services to the residents of the facility. Findings included: - Review of four staff personnel files/in-service training records revealed two of the four, CNA L and CNA M, lacked all 12 hours of required trainings which included dementia training, resident abuse prevention, social media training and cares for individuals with cognitive impairments. On 10/03/23 at 11:23 AM, Administrative Staff A and Consultant Nurse K confirmed the facility lacked documentation of the in-service training for the two staff members reviewed. The facility lacked a policy regarding retention of education records as requested on 10/03/23. The facility failed to maintain in-service training program records that was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-03 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 44 residents with 12 residents selected for review, including three residents reviewed for use of side rails, Resident (R)18, R7 and R6. Based on observation, interview, and record review, the facility failed to perform routine inspections of the bed rails to ensure they met safety standards and were not a risk for resident entrapment or perform safety assessments of residents with bed rails attached to their beds. The facility reported 24 residents had a rail or other assistive device on the bed, and nine of those bedrails were loose. These deficient practices led to the possibility of injury or entrapment for these 24 residents. Findings included: - R6's Electronic Medical Record (EMR) revealed the resident had a diagnosis that included adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals, especially people with multiple chronic medical conditions), history of transient ischemic attack (TIA is a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-03 · tag F0641 — isolatedEnsure 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 44 residents with 12 residents sampled. Based on interview and record review, the facility failed to complete an accurate Minimum Data Set (MDS), for one of the 12 residents sampled, resident (R)12, related to her life expectancy of six months or less for this resident that received hospice services. Findings included: - The Physician Orders for Resident (R)12, dated 09/28/23, included diagnoses of myocardial infraction (heart attack), and hypertensive (high blood pressure) heart disease with heart failure. The Significant Change in Status Minimum Data Set, (MDS) dated [DATE], documentation included R 12 received hospice care, however the documentation lacked that the resident did not have a terminal condition or chronic disease that may result in a life expectancy of less than 6 months. On 09/28/23 at 09:49 AM, Licensed Nurse (LN) D, confirmed the resident received hospice services and her life expectancy was six months or less. On 09/28/23 at 11:08 AM, LN E verified 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 · F2022-02-08 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
The facility had a census of 34 residents. Based on interview and record review the facility failed to ensure the minimum required members attended the Quality Assessment and Performance Improvement (QAPI) meetings on at least a quarterly basis. Findings included: - Review of the QAPI meeting sign-in sheets from 01/14/21 through 01/27/22 revealed the following missing signatures of attendance: 01/14/21- Medical Director (MD) 02/18/21- MD 03/25/21- MD 04/22/21- MD 06/27/21- MD 07/22/21- MD 12/13/21- Director of Nursing (DON) 01/27/22- MD Interview on 02/07/22 at 04:58 PM, Administrative Staff A stated the medical director should be present during the quarterly QAPI meetings. The 07/2021 Quality Assessment and Performance Improvement Committee policy documented required committee members included the Administrator, Director of Nursing Services, and Medical Director. The facility failed to ensure the minimum required members attended the QAPI meetings on at least a quarterly basis.
- Potential for harm · Ecited before2022-02-08 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 34 residents with five residents reviewed for unnecessary medications. Based on observation, interview and record review the facility failed to provide evidence of monthly monitoring of medication regimen by a licensed pharmacist for Resident (R)21, R5, R3, R33. Findings included: - Resident (R) 21's signed Physician Orders dated 12/31/21 revealed the following diagnoses: symptoms and signs involving cognitive functions and awareness (dementia-progressive mental disorder characterized by failing memory, confusion), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), ascites (buildup of fluid in the abdomen, often due to severe liver disease), obstructive hypertrophic cardiomyopathy (heart disease), chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), paranoid schizophrenia (a thought process believed to be heavily…
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 · E2022-02-08 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure 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 34 residents with five residents reviewed for unnecessary medications. Based on interview, observation, and record review, the facility failed to ensure two residents, Resident (R)21 and R5, were free of unnecessary medications by the failure to check blood sugars (BS) and give medications as ordered. Findings included: - Resident (R) 21's signed Physician Orders dated 12/31/21 revealed diagnoses of symptoms and signs involving cognitive functions and awareness (dementia-progressive mental disorder characterized by failing memory, confusion diabetes mellitus (DM; when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin). The 03/19/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The resident required limited assistance of one staff for daily care. The resident received as needed (PRN) pain medications. The resident was short of breath (SOB) when…
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 before2022-02-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 34 residents. The facility had one main kitchen where the food was stored and prepared serving one dining room. Based on observation, interview, and record review the facility failed to ensure the dishes and cookware were washed under sanitary conditions due to the lack of accurate chemical monitoring. Findings included: - Observation on 02/01/22 at 11:58 AM revealed Dietary Staff (DS) Q demonstrated chemical sanitization test. She dipped a test strip in the water reservoir for 15 seconds. The test strip did not change color which indicated zero parts per million (PPM). At 12:00 PM Certified Dietary Manager (CDM) R told DS Q to hold a new test strip in the water longer. The new test strip indicated zero PPM. CDM R primed the chemical hose and another test strip was dipped in the water reservoir which still did not change color which indicated zero PPM. The test strip bottle was checked for an expiration date and it was determined the strips were not expired. A new bottle of test strips was opened, and a strip was run through a whole wash and rinse…
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 · D2022-02-08 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 34, with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to ensure staff notified Resident (R)3's representatives of changes. Findings included: - R3's Order Summary Report dated 01/04/22 documented the following diagnoses: hypotension (low blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), difficulty walking, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, syncope (fainting or passing out) and collapse (when one becomes falls to the ground and does not respond to sounds or being shaken). The 01/14/22 Medicare 5-day Minimum Data Set (MDS) documented a Brief Interview for Mental Status BIMS score of 10 which indicated moderately impaired cognition. The 04/26/21 Nursing Note documented nursing staff notified the Director of Nurses (DON) and the provider but made no mention the Durable Power Of Attorney (DPOA) was notified after R3 had a fall. The 09/15/21 Nursing Note…
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 · D2022-02-08 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 34 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to provide written notice to the State Ombudsman of the 10/09/21 facility-initiated hospitalization transfer of Resident (R)1. Findings included: - R1's Order Summary Report dated 01/04/22 documented diagnoses of urinary tract infection and opioid dependence. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Quarterly MDS dated 01/15/22 revealed a BIMS score of 15, which indicated intact cognition. The 10/09/21 Nursing Note documented R1 had an oxygen saturation level of 81 percent, a blood pressure of 81/50 millimeters of mercury (mm/Hg), pulse of 80 beats per minute, and respirations of 32 per minute. R1 was cyanotic (bluish discoloration of the skin), unresponsive, and unable to follow commands or respond to staff. Emergency Medical Services (EMS) was…
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 · D2022-02-08 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 34 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to provide Resident (R)1 or their representative with a bed hold policy upon transfer to the hospital on [DATE]. Findings included: - R1's Order Summary Report dated 01/04/22 documented diagnoses of urinary tract infection and opioid dependence. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The 10/09/21 Nursing Note documented R1 had an oxygen saturation level of 81 percent, a blood pressure of 81/50 millimeters of mercury (mm/Hg), pulse of 80 beats per minute, respirations of 32 per minute. R1 was cyanotic (bluish discoloration of the skin), unresponsive, and unable to follow commands or respond to staff. Emergency Medical Services (EMS) was immediately notified of emergent situation. R1 transferred to a local hospital by ambulance for further treatment 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 · D2022-02-08 · 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
The facility census totaled 34 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to revise the care plan to include the use of oxygen therapy and care of oxygen equipment for Resident (R)21 and update the care plan to include new fall interventions to prevent further falls for R3. Findings included: - Resident (R) 21's signed Physician Orders dated 12/31/21 revealed diagnoses of symptoms and signs involving cognitive functions and awareness (dementia-progressive mental disorder characterized by failing memory, confusion), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), ascites (buildup of fluid in the abdomen, often due to severe liver disease), obstructive hypertrophic cardiomyopathy (heart disease), and chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 03/19/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-02-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 34, with 12 residents included in the sample, and one resident reviewed for accidents. Based on observation, interview, and record review the facility failed to identify causal factors related to a fall experienced by R3, which resulted in a hematoma to his head, and failed to implement new fall prevention intervention after the fall. Findings included: - The signed Order Summary Report dated 01/04/22 documented the following diagnoses: hypotension (low blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), difficulty walking, Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, syncope (fainting or passing out), and collapse (when one becomes falls to the ground and does not respond to sounds or being shaken). The 01/14/22 Medicare 5-day Minimum Data Set (MDS) documented a Brief Interview for Mental Status BIMS score of 10 which indicated moderately impaired cognition. R3…
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 before2022-02-08 · 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
The facility census totaled 34 residents with 12 included in the sample and 1 resident reviewed for respiratory services. Based on observation, interview, and record review the facility failed to obtain physician orders prior to the use of oxygen therapy for Resident (R) 21. Findings included: - Resident (R) 21's signed Physician Orders dated 12/31/21 revealed diagnoses of symptoms and signs involving cognitive functions and awareness (dementia-progressive mental disorder characterized by failing memory, confusion), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), ascites (buildup of fluid in the abdomen, often due to severe liver disease), obstructive hypertrophic cardiomyopathy (heart disease), chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin). The 03/19/21 Annual Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-08 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 34 residents with 12 included in the sample and one resident reviewed for dialysis (the clinical purification of blood, as a substitute for the normal function of the kidney). Based on observation, interview, and record review, the facility failed to ensure staff documented assessments of Resident (R) 3's dialysis fistula (a surgical connection between an artery and a vein used for dialysis treatment) site and post dialysis weights. Findings included: - The 01/04/21 signed Order Summary Report documented a diagnosis of end stage renal disease (a terminal disease because of irreversible damage to kidneys). The 01/14/22 Medicare 5-day Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The resident received dialysis services. The 09/28/21 Dehydration/Fluid Maintenance Care Area Assessment (CAA) documented R3 had a diagnosis of end stage renal disease and required dialysis three times a week. He received a regular diet and was on a fluid restriction. The 11/18/21 Care…
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 · D2022-02-08 · 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
The facility reported a census of 34, with 12 residents included in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure completion of targeted behavior monitoring for Resident (R)3 and continued to administer R33's as needed (PRN) psychotropic medication longer than 14 days without a renewed physician order or reason provided by the physician for the continued administration of lorazepam (anti-anxiety medication) on a PRN basis. Findings included: - R3's signed Order Summary Report dated 01/04/22 documented the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The 01/14/22 Medicare 5-day Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) score of 10 which indicated…
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 before2020-09-14 · 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 census totaled 37 residents. The facility had one main kitchen where dietary staff prepared all food. Based on observation, interview, and record review the facility failed to prepare food items in a sanitary manner by the failure of dietary staff to change gloves between the touching of food items and dirty surfaces and failed to store food items in a sanitary manner by the failure to date food items placed in the refrigerator. These failures had the potential to affect all residents. Findings included: - Observation on 09/14/20 at 12:00 PM revealed Dietary Staff (DS) D cut up cucumber for a salad with gloved hands. DS D grabbed the trash can by her station and placed the cut end of the cucumber into the trash can, turned to handle the cucumber with the same gloved hand that had touched the trash can, and continued to cut up the cucumber. Interview on 09/14/20 at 12:03 PM with DS D revealed she always wore the same gloves throughout food preparation and reported she did not know the gloves were to be changed after handling the trash can. Interview on 09/14/20 at 12:20…
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.
- No harm found · C2023-10-03 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 44 residents with 12 sampled for review. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) with complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS {i.e., Payroll Base Journal (PBJ)}, related to licensed nursing staff coverage and decrease in weekend staffing. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 1 2023, (October 01 thru December 31) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24/7) on the following dates: On 10/09; Sunday (SU), On 11/12: Saturday (SA), On 11/13 (SU), On 11/19 (SA), On 11/20 (SU), On 12/03 (SA), On 12/17 (SA), On 12/18 (SU), On 12/26: Monday (MO). Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 2, 2023, (January 1 through March…
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.
- No harm found · C2022-02-08 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility reported a census of 34 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to inform the residents who attended resident council of the location of the state survey notebook and failed to inform residents of the right to read the survey results. This notebook contained only two years of survey results in the notebook (2020 and 2021). Findings included: - Observation on 01/31/22 at 02:00 PM during the initial tour of the facility, the state survey results were not located. There was no signage posted to indicate the location of the survey results. Observation on 02/01/22 at 11:30 AM revealed the State Survey Book was on a counter by the front entrance of the facility. This notebook contained only two years of survey results in the notebook (2020 and 2021). On 02/01/22 at 01:32 PM during the resident council meeting, Resident (R)23 stated she did not know the location of the state survey notebook. The facility's Examination of Survey Results Opportunity to Contact Agencies F577 policy dated 05/2021 documented A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$40,104 in federal fines across 3 penalties.
- $14,293 — penalty dated 2025-03-11
- $13,250 — penalty dated 2025-02-21
- $12,561 — penalty dated 2024-12-30
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MISSION HEALTH COMMUNITIES — 30 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.8 | -1.8 vs chain |
| Health inspection | 1 of 5 | 2.9 | -1.9 vs chain |
| Staffing | 3 of 5 | 2.9 | +0.1 vs chain |
| Quality measures | 2 of 5 | 2.9 | -0.9 vs chain |
The other 29 homes this chain runs (chain average 2.8★, per CMS)
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 |
|---|---|---|---|---|
| CORONADO OPERATOR, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2019 |
| BARRES, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2019 |
| CURIS HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2019 |
| T AND C CAPITAL ASSETS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2019 |
| WINDWARD HEALTH PARTNERS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2019 |
| YOAKUM, JAMIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/24/2024 |
| MISSION HEALTH COMMUNITIES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2019 |
| WICHITA OPERATOR LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2019 |
| LINDEMAN, STUART | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2019 |
| THOMAS, TINA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2019 |
CMS files one row per role, so the 11 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
7 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.
About 93% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $231K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 175273. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-10-03, 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.