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Wilson Care And Rehab

611 31st Street, Wilson, KS 67490 · For profit - Limited Liability company · 40 certified beds · (785) 658-2505 Medicare & Medicaid certified

Call the home — (785) 658-2505 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (65%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2509 Ave E · (785) 658-3688 · Call to confirm hours
Pharmacy
Seitz Drug14.7 mi
206 N Douglas Ave · (785) 472-3212 · Call to confirm hours
Grocery
2720 Avenue E · (785) 658-2559 · Call to confirm hours
Park
2407 Avenue E · (785) 658-2272 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.8%17.9%15.4%worse
Long-stay residents who lose too much weight11.3%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection5.4%2.9%2.0%worse
Long-stay residents with depressive symptoms17.7%6.5%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.7%4.3%3.3%better
Long-stay residents whose ability to walk worsened12.6%16.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.0%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine97.3%95.5%95.3%typical
Long-stay residents with pressure ulcers11.2%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control25.5%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table20.4%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better
Long-stay hospitalizations per 1,000 resident days2.081.801.67worse
Long-stay outpatient ER visits per 1,000 resident days3.642.131.80worse

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

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

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

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

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

50.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.1%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
0.16U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.1%CMS range 39.0–62.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.2–16.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identified83.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 3.9–15.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.301.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.79
RN hours/ resident / day
0.26
LPN hours/ resident / day
2.64
Aide hours/ resident / day
3.68
Total nurse hours/ resident / day
0.41
RN hoursweekends
65.1%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 40 beds and averages 37.3 residents a day — about 93% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.64 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 3.84 on weekdays — 14% thinner on weekends. RN hours go from 0.94 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-12-11)
9
at the previous standard inspection (2024-02-05)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Fcited before2025-12-11 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 34 residents, with 12 included in the sample. Based on observation, record review, and interview, the facility failed to ensure nursing staff donned (put on) the appropriate required Enhance Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) before providing direct cares to Resident (R) 5 and ensure staff did not set R5's catheter bag (medical device that collects urine) directly on the resident's floor. The facility failed to ensure nursing staff donned the required EBP and performed hand hygiene prior to and during the wound dressing change for R15. Findings included:- On 12/10/25 at 11:23 AM, Licensed Nurse (LN) G gathered and prepared wound care supplies (placed gauze pads into a clean plastic cup and placed zinc ointment into a clean cup) on the treatment cart outside of R15's room. LN G gathered the wound care supplies in her hands as she knocked on R15's door to announce herself and explained she was going 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-11 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to resolve recurring issues reported by the Resident Council. Findings included:- A review of the facility's Resident Council Minutes from 12/10/24 to 11/28/25 indicated the council had recurring concerns with call light response times and delivery of care. The Resident Council Minutes for 04/08/25 noted the resident's had concerns with call lights being turned off, staff leaving, and then not returning to complete their requests. In addition, the council requested that staff be quiet during activities like church and movies. The facility's response to the council's concern included that staff were provided with re-education pertaining to answering resident call lights and noted staff would show respect during activities such as church or movies at the nurse's station. The Resident Council Minutes for 05/28/25 again noted the resident call lights were being turned off by staff without completing cares, staff remaining loud during…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-11 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 34 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or representative) a fully completed Advanced Beneficiary Notice (ABN) Centers for Medicare and Medicaid Services (CMS) Form 10055 for skilled services for Resident (R) 2, R20, and R28, which included the estimated cost of services.Findings included:- The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that they may not pay for future skilled therapy services and provided a place for a cost estimate of continued services. The form included an option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. The form had a place for the resident to document they understood that if Medicare did not pay, they were responsible for payment but could appeal to Medicare. The form further documented under part (2) the resident could receive therapy listed, but would not bill Medicare, would be responsible…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 identified a census of 34 residents. The sample included 12 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the omission of blood pressure or pulse monitoring for Resident (R) 4 prior to the administration of the antihypertensive (a class of medication used to treat high blood pressure) beta blocker (a medications that reduce the workload of the heart by slowing its rate and relaxing blood vessels) Carvedilol. The facility failed to implement recommendations made by the CP for a dosage amount for R4's Voltaren gel (a topical medication used to relieve arthritis pain). Findings included:- R4's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- elevated blood pressure), aneurysm of the heart (a bulge in the weakened wall of the heart), traumatic brain injury (damage to the brain from an external force, like a blow,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 12 residents, with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that blood pressure or pulse monitoring was obtained for Resident (R) 4 prior to the administration of the antihypertensive (a class of medication used to treat high blood pressure) beta blocker (a medications that reduce the workload of the heart by slowing its rate and relaxing blood vessels) Carvedilol. The facility failed to ensure a physician-ordered dosage amount was indicated for R4's Voltaren gel (a topical medication used to relieve arthritis pain). Finding included:- R4's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- elevated blood pressure), aneurysm of the heart (a bulge in the weakened wall of the heart), traumatic brain injury (damage to the brain from an external force, like a blow, jolt, or penetrating object, causing physical, cognitive,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's injectable medications were not expired. Findings included:- On [DATE] at 08:11 AM, during the medication/treatment cart initial tour, two Lispro injectable pens with an open date of [DATE] were noted for R2. Licensed Nurse (LN) G verified the medication was put into use on [DATE] and expired 30 days after being opened and put into use. On [DATE] 12:55 PM, Administrative Nurse D verified R2's Lispro injectable pens expired 30 days from the open date and stated the pens should be discarded. The facility's Storage of Medication policy, dated 03/2025, documented that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulation.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 12 residents, with one resident, Resident (R) 7, reviewed for Hospice care. Based on observation, record review, and interview, the facility failed to ensure the collaboration of care between R7's hospice provider and the facility which included the hospice provider contact information, the services the hospice provider would provide to the resident, the supplies, equipment and medications the hospice provider would provide, as well as how often hospice staff members would visit the facility. Findings included: - R7's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- elevated blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), benign hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to ensure appropriate sanitation of dishware used for preparing, and serving residents' meals, and failed to prepare, store, distribute, and serve food under sanitary conditions for the 34 residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food-borne illness. Findings included: - On 01/30/24 at 08:40 AM, observation revealed Dietary Staff (DS) CC operated the dishwasher and attempted to test the dishwasher rinse for chemical sanitation. The wash and rinse temperatures were 105 degrees Fahrenheit (F). DS CC used sanitizer testing strips which indicated no chemicals. The dishwasher was connected to Betco low-temperature machine sanitizer and used [NAME] All Temperature Rinse Aide and [NAME] All Temperature Dish Machine Detergent. The Dishwasher Temperature Logs, dated January 2024,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-05 · tag F0851 — widespread
    Electronically 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 had a census of 34 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 the PBJ report for Quarter 2 indicated the facility had excessively low weekend staff. The PBJ report for Quarter 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on following days: 04/01/23, 04/02/23, 04/08/23, 04/15/23, 04/17/23, 04/19/23, 04/22/23, 04/29/23, 04/30/23, 05/06/23, 05/20/23, 05/27/23, 05/28/23, 06/03/23, 06/10/23, 06/11/23, 06/24/23, and 06/25/23 and had excessive low weekend staff. A review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 02/05/24 at 01:15 PM, Administrative Staff 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-05 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 34 residents. Based on observation, record review, and interview the facility failed to resolve grievances recorded during resident council meetings. This placed the residents at the facility at risk for unresolved grievances and decreased quality of life. Findings included: - Review of the Resident Council Minutes from February 2023 to January 2024 recorded grievances from the resident council which staff had not addressed the residents' concerns regarding Certified Nurse Aides (CNA) and staff on their personal phones during care (five meetings the concern was expressed), too much noise at nights and TV too loud in the commons area (six meetings the concern was expressed), short staffing (three meetings the concerns were expressed), and various other concerns not addressed. A review of the facility's Grievance/Variance Log from January 2023 to December 2023 recorded grievances that were unresolved or ongoing. On 02/01/24 at 09:30 AM, In an interview with four residents, the residents verbalized they had concerns and grievances with the above-documented…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2024-02-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. Based on observation, interview, and record review, the facility failed to label insulin (a hormone that lowers the level of glucose in the blood) pens or vials with an opened date or discard date. This placed residents who received the insulins at risk for expired or ineffective insulin. Findings included: - On [DATE] at 08:29 AM, observation revealed the facility's nurses cart held six insulin pens that had not been dated when opened: One Lantus (long-acting insulin) pen open with no date, for Resident (R)16. One Lantus pen and one Humalog (fast-acting insulin) pen, open with no date for R31. One Lispro (rapid-acting insulin) pen, open with no date for R3. One Lantus pen opened, with no date for R9. One Lantus pen opened, with no date, for R30. On [DATE] at 08:29 AM, Licensed Nurse (LN) H verified the lack of dates and stated nurses were to write the date on the insulin pens or vials when they were first opened for use. The facility's Insulin Administration policy,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-05 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 34 residents. The sample included 12 residents with five residents reviewed for immunizations, Resident (R)3, R4, R10, R16, R19, and R87, to include pneumococcal vaccinations (helps protect against serious illnesses like pneumonia). Based on record review and interviews, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV 20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - Review of R3, R4, R10, R16, R87, and R19's clinical medical records lacked evidence the facility or the resident representative received or signed consent or informed declination for the current pneumococcal vaccine PCV20. On 02/05/24 at 11:30 AM, Administrative Nurse D stated the facility was reviewing resident records to determine if they were eligible for the newest PCV 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-05 · tag F0623 — isolated
    Provide 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 had a census of 34 residents. The sample included 12 residents with one reviewed for hospitalization. Based on observation, interview, and record review the facility failed to notify the state's Long Term Care Ombudsman (LTC) Ombudsman (a person who advocates for residents of nursing homes), as required, of Resident (R) 19's discharge from the facility. This placed the resident at risk for impaired rights and/or advocate involvement. Findings included: - R19 's Electronic Medical Record documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polycythemia vera (a chronic blood disorder), malnutrition, cerebral infarction (stroke), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), sepsis (life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body),…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-05 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — 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. The sample included 12 residents with one reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide Resident (R)19 with a Bed Hold Notice (the right of an individual to resume nursing facility residency after he or she has been away from the facility due to hospitalization or therapeutic leave). This placed the resident at risk of not being allowed to return to the same room upon discharge from the hospital. Findings included: - R19 's Electronic Medical Record documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), polycythemia vera (a chronic blood disorder), malnutrition, cerebral infarction (stroke), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), sepsis (life-threatening systemic reaction that develops due to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-05 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported an inappropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of Resident (R)31's antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions). This placed the resident at risk for unnecessary medications and related side effects. Findings included: - R31's Physician Order Sheet (POS), documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) with behavioral disturbance, and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 34 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality testing) for Resident (R)31. This deficient practice placed the resident at risk for unnecessary psychotropic medication and related complications. Findings included: - R31's Physician Order Sheet (POS), documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) with behavioral disturbance, and cerebral infarction (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…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-09-26 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to monitor laundry temperatures to ensure proper disinfection and cleaning of soiled linens and clothing. This deficient practice placed residents at risk for infection and illness. Findings included: - On 09/21/22 at 12:00 PM, observation in the facility's laundry rooms revealed Housekeeping V checked the temperature logs for the washing machines. Washer 1 (small one used for bleaching) temperature log for August 2022 lacked documentation on 8/1, 8/9, 8/19, 8/20, 8/21, 8/30, and 8/31. Washer 3 (commercial) August 2022 temperature log lacked documentation of temperatures on 8/1, 8/9, 8/11-24, 8/30, and 8/31. The September 2022 temperature logs for Washer 3 lacked documentation from 9/1/22 to 9/9/22. On 09/21/22 at 12:10 PM, Housekeeping V verified the lack of documentation for the washing temperatures. The facility's Soiled Laundry and Bedding policy, dated 11/2017, recommended guidelines for laundry cycles were hot water 160F for 25…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-09-26 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to provide an environment reasonably free of insects. This deficient practice placed the residents of the facility at risk for irritation and potential insect borne illnesses. Findings included: - 09/20/22 at 11:20 AM, observation in the facility kitchen revealed numerous common flies on surfaces and flying round. The kitchen did not have an outside exit. On 09/20/22 at 11:50 AM the dining room where residents ate their meals also had numerous flies landing on surfaces including their beverages and persons. On 9/20/22 at 12:10 PM, observation in the dining room revealed numerous flies throughout the meal service landed the tip of a resident's sippy cup. Continued observation revealed flies landed on the tables, and on residents' food. Resident (R) 18 had a fly swatter he brought to the dining room from his room and swatted the flies when they landed on his table. R18 got up from the table without his walker to swat the flies. On 09/21/22…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-09-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to store hazardous cleaning chemicals in a safe manner. This deficient practice placed the five cognitively impaired, independently mobile residents at risk for injury and/or accidents. Findings included: - On 09/20/22 at 09:05 AM, observation revealed a one-quart spray bottle of CLR mold and mildew stain remover, labeled: keep out of reach of children, avoid contact with eyes or clothing, was found under the sink in an unlocked cabinet in the family/conference room. On 09/20/22 at 09:05 AM, Administrative Staff A verified the chemical should be locked away. On 09/20/22 at 09:10 AM, observation revealed the west soiled utility room unlocked with a quart spray bottle of all-purpose cleaner labeled: flammable, wear rubber gloves, on the counter. The door did not lock even though it had a keypad lock. On 09/20/22 at 09:10 AM, Housekeeping Staff U verified the door should be locked. On 09/20/22 at 09:20 AM, observation revealed the east hall…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-09-26 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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 - R17's Physician Order Sheet (POS), dated 08/01622 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion,) cerebral ischemia (acute brain injury that results from impaired blood flow to the brain,) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R17's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of five (moderately impaired cognition). The MDS recorded the resident required extensive assistance of one to two staff for bed mobility, locomotion on the unit, dressing and personal hygiene. The MDS documented R17 received an antipsychotic medication seven days during the lookback period. R17's Cognitive Loss/Dementia Care Area Assessment, dated 01/05/22 recorded the resident was prescribed an antipsychotic. R17's Care Plan, dated 08/01/22 documented the resident had impaired thought process due to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-26 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 38 residents. The sample included 12 residents. Based on interview, and record review the facility failed to provide the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), CMS form 10055, which contained an estimated cost to continue services for skilled services, at the end of the skilled stay. This deficient practice placed three of three sampled residents, Resident (R) 24, R29, and R31, at risk for uninformed decisions regarding skilled services. Findings included: - The CMS SNF ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 187 who smoked which placed the resident at risk of unidentified and/or uncommunicated care needs related to smoking. Findings included: - R187's diagnoses included encephalitis (inflammatory condition of the brain), alcohol dependence with withdrawal, complete traumatic amputation (surgical removal) at knee level right lower leg, complete traumatic amputation of left foot at ankle level, alcohol induced disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear disorder, and major depressive (major mood disorder) disorder. The Quarterly Minimum Data Set, dated 08/19/22, recorded R187 had intact cognition, was independent with supervision for activities of daily living. R187 was not steady, but able to stabilize without staff assistance with transition, had functional range of motion impairment to lower extremities both sides. He…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R)25 received the necessary treatments and cares related to treatment of skin tears when staff failed to use appropriate hand hygiene during wound care and failed to accurately apply dressings and monitor as ordered by the physician. These deficient practices placed the resident for incomplete death record and delayed wound healing. Findings Included: - R25's diagnoses included anxiety disorder, major depressive disorder (mood disorder characterized by severe sadness), and dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion,) . The 5 day Minimum Data Set (MDS), dated [DATE], documented staff assessed R25 had severe cognitive impairment, required extensive assistance of two staff for activities of daily living, was not steady during transition and only able to stabilize with staff…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-26 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 had a census of 38 residents. The sample included 12 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) . Based on observation, record review, and interview, the facility failed to provide ongoing communication and assessment of Resident (R) 16's dialysis treatment. This placed the resident at risk for complications and health decline. Findings included: - R16's Physician's Order Sheet, dated 09/17/22 documented the resident had diagnoses of end stage renal disease (decline in kidney function.) R16's admission Minimum Data Set (MDS), dated 07/22/22, recorded R16 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS recorded he required extensive assistance of two staff for bed mobility, transfers, limited assistance of one staff with personal hygiene, and limited assistance of two staff with toilet use. The MDS further recorded R16 was occasionally incontinent of urine and recorded the resident received…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R17's Physician Order Sheet (POS), dated 08/01622 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion,) cerebral ischemia (acute brain injury that results from impaired blood flow to the brain,) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R17's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of five (moderately impaired cognition). The MDS recorded the resident required extensive assistance of one to two staff for bed mobility, locomotion on the unit, dressing and personal hygiene. The MDS documented R17 received an antipsychotic medication seven days during the lookback period. R17's Cognitive Loss/Dementia Care Area Assessment, dated 01/05/22 recorded the resident was prescribed an antipsychotic. R17's Care Plan, dated 08/01/22 documented the resident had impaired thought process due to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-26 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)10, R16, R20, and R84's insulin (hormone which allows cells throughout the body to uptake glucose) pens with the date opened and expiration date. This placed these residents at risk for ineffective medications. Findings included: - On [DATE] at 08:30 AM, observation of the nurse's medication/treatment cart, revealed the following: R10's Levemir (long acting insulin) flex pen lacked a date opened, and a date of expiration. R 16's Lantus (long acting insulin) flex pen lacked a date opened, and a date of expiration. R20's Humalog (fast acting insulin) flex pen lacked a date opened, and a date of expiration. R84's Lantus (long acting insulin) flex pen lacked a date opened, and a date of expiration. On [DATE] at 08:40 AM, Licensed Nurse (LN) G, verified the nurses were to date the insulin pens/vials when opened and discard the expired insulin. On…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-26 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 38 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and implemented for Resident (R)30. This placed R30 at risk for inappropriate end of life cares. Findings included: - R30's Physician Order Sheet, dated 09/19/22, revealed diagnoses of atrial fibrillation (rapid, irregular heartbeat), dysphagia (swallowing difficulty), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and pain. R30's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R30 had severely impaired cognition. The MDS…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-09-26 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to post daily staffing in a public place. Findings included: - On 09/20/22 at 09:45 AM, no posting of staff was found in common areas, or entry. Administrative Staff A was unable to locate the posted staffing at that time as well. An unidentified charge nurse brought Administrative Staff A a binder with the daily staffing sheets. The 9/20/22 daily sheet was completed with names, and shifts, but no hours. The staffing sheets also had names of residents with noted appointments and showers written on it. The binder was kept in a drawer in the nurse's desk. On 09/21/22 at 10:45 AM, no nursing staff was posted. on 09/21/22 at 01:55 PM Certified Medication Aid (CMA) R verified the daily staffing was not posted. She provided the daily staffing binder from the desk drawer at the nurse's desk. On 09/22/22 at 08:47 AM, no staffing was posted. Administrative Nurse D verified the staffing for the day should be posted in a public place. 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

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

RatingThis homeChain avg
Overall 3 of 52.8+0.2 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 2 of 52.9-0.9 vs chain
Quality measures 2 of 52.9-0.9 vs chain
The other 29 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Colby Operator, LLCColby, KS 1 of 5Dickson Health And RehabDickson, TN 1 of 5Hutchinson Operator, LLCHutchinson, KS 1 of 5Kaw River Care And RehabEdwardsville, KS 1 of 5Lincoln Care And RehabWichita, KS 1 of 5North Ridge Health And RehabNew Hope, MN 1 of 5Providence Living CenterTopeka, KS 2 of 5Columbus Health and RehabColumbus, WI 2 of 5Edwardsville Care And RehabEdwardsville, KS 2 of 5El Dorado Care And RehabEl Dorado, KS 2 of 5Spring Hill Care And RehabSpring Hill, KS 3 of 5Chase County Care And RehabCottonwood Falls, KS 3 of 5Eskridge Care And RehabEskridge, KS 3 of 5Lansing Care And RehabLansing, KS 3 of 5McPherson Operator, LLCMcPherson, KS 3 of 5Neodesha Care And RehabNeodesha, KS 3 of 5Parkway Operator LLCEdwardsville, KS 3 of 5Pittsburg Care And RehabPittsburg, KS 3 of 5Rolling Hills Health And RehabWichita, KS 4 of 5Arma Operator, LLCArma, KS 4 of 5Onaga Operator, LLCOnaga, KS 4 of 5Oswego Operator, LLCOswego, KS 4 of 5Peabody Health And RehabPeabody, KS 4 of 5Pratt Health And RehabPratt, KS 4 of 5Smith Center Health And RehabSmith Center, KS 4 of 5Wakefield Care And RehabWakefield, KS 5 of 5Botkin Care And RehabWellington, KS 5 of 5Downs Care And RehabDowns, KS 5 of 5Wellington Health And RehabWellington, KS

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

Who owns this facility

Owner / managerTypeRoleShareSince
CORONADO OPERATOR, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/01/2019
BARRES, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2019
CURIS HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2019
T AND C CAPITAL ASSETS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2019
WINDWARD HEALTH PARTNERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2019
LINDEMAN, STUARTIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/24/2024
YOAKUM, JAMIEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/24/2024
MISSION HEALTH COMMUNITIES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019
WILSON OPERATOR, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019
THOMAS, TINAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2019

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

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.

$4.6M
Net patient revenuemost recent cost report
+11.0%
Operating marginrevenue minus expenses
$215K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 17%Other / private 17%

This home reported $215K 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

$305per resident / day
operating cost
$9,260per month
≈ monthly operating cost
$342per day
avg. revenue, all payers

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

What families pay in KS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175205. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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