Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crowley County Nursing Center during CMS and state inspections, most recent first.
Staff failed to follow infection control practices during resident care and meal assistance. An CNA and an LPN did not don PPE while obtaining vital signs for residents on EBP, vital signs equipment and personal devices such as a pulse oximeter and stethoscope were used without being sanitized between resident use, and CNAs did not perform hand hygiene between assisting multiple residents with meals in the dining room.
Delayed replacement of missing hearing aids. A resident with cognitive intactness and documented bilateral hearing loss was found without her hearing aids and reported difficulty hearing conversations and the TV. Records showed the aids were missing, audiology confirmed moderate-to-severe loss and recommended bilateral amplification, but the facility continued waiting on PETI approval even after a payment denial was received, and no further documentation showed the aids were replaced.
A resident with DM, anemia, depression, CHF, pressure ulcers, and protein-calorie malnutrition experienced severe weight loss and was visibly emaciated. The resident frequently refused Glucerna and protein liquid, disliked the taste of the supplements, and often ate little or no food, yet the record did not show meaningful follow-up to the repeated refusals or updated assessment of food preferences. Although the RD suggested an appetite stimulant and the resident was on hospice, no alternate nutritional interventions were documented despite continued low intake and ongoing weight loss.
Failure to Address Suicidal Ideation and Trauma-Related Distress: A resident with major depression, dementia, suicidal ideations, and a significant trauma history repeatedly expressed that she wanted to die, was ready to be with her husband, and made other hopeless statements while refusing meds and care and isolating in her room. Although staff documented grief, mood, and psychosocial concerns, the suicidal ideation care plan was not started until during the survey, and the record showed missed notifications and no lethality assessment after some suicidal statements.
A resident with no natural teeth had his dentures lost and remained without replacement for months while the facility pursued insurance and PETI payment. Records showed repeated denials, delayed submission of PETI paperwork, and ongoing lack of follow-up, while the resident reported sore gums, chewing difficulty, and pain.
Infection Control Failures During EBP Care, Equipment Use, and Meal Assistance
Penalty
Summary
The facility failed to maintain an infection control program in several observed areas, including enhanced barrier precautions, sanitation of vital signs equipment, and hand hygiene during meal assistance. The report identified failures on two halls and in the main dining room, with observations showing staff actions that did not follow the facility’s infection control expectations. For enhanced barrier precautions, an unidentified CNA entered a resident’s room on Hall A and obtained vital signs without donning PPE. On Hall D, an LPN entered the room of a resident on EBP related to an indwelling device without PPE, placed a blood pressure machine beside the bed, applied the cuff with bare hands, touched the resident’s skin, and leaned on the bed rail with a bare arm while the resident took medications. Staff interviews reflected that EBP was understood by some staff to require gown and glove use during direct care, including vital sign collection, but the observed care did not follow that practice. Vital signs equipment was also observed being used without sanitation between residents. A staff member obtained a resident’s blood pressure near the nurses’ station and did not sanitize the machine before or after use. An unidentified CNA used the same machine to take vital signs for a resident on EBP without sanitizing it before entering the room or after leaving. In addition, an LPN removed a pulse oximeter from her pocket and used it on a resident without cleaning it, then returned it to her pocket, and used a stethoscope on another resident without cleaning the diaphragm afterward. Hand hygiene failures were observed during meal assistance in the dining room. One CNA, wearing disposable gloves, fed three residents and did not perform hand hygiene between assisting each resident. During another meal observation, CNA #3 assisted two residents at different times, used the same hand while helping both residents, and did not perform hand hygiene between them until later when she walked to another table and used hand sanitizer. The DON stated staff should perform hand hygiene before assisting residents with meals and between residents if switching from one resident to another.
Delayed Replacement of Missing Hearing Aids
Penalty
Summary
The facility failed to ensure that Resident #31’s missing hearing aids were replaced in a timely manner. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had a history of hemiplegia and hemiparesis following a cerebral infarction and was documented as having impaired hearing. During interview, she was not wearing hearing aids and stated that her hearing aids had been lost some time ago, that she had not received an update about new ones, and that without them she missed parts of conversations and had trouble hearing the television. Record review showed that the resident’s hearing care plan identified bilateral hearing aids as missing and noted audiology evaluations on 3/20/23 and 2/26/26. The audiology report documented moderate-to-severe hearing loss in both ears, stated that the resident reported her current hearing aids were lost, and indicated that new hearing aids would need to be ordered. The report also noted that the resident was not provided a hearing amplification device. The annual care conference summary stated the facility was waiting on PETI approval for new hearing aids, while a social services note documented that the hearing aids were missing and a new evaluation was needed for PETI processing. Further record review showed that a payment denial letter was received on 3/11/26 stating the request for PETI nursing facility services had been denied because the hearing aids had been replaced on 10/17/24 and state rule allowed replacement only every five years. Despite that denial, a later social services note still documented that the facility was waiting on PETI approval for new bilateral hearing aids. No further documentation was found regarding replacement of the hearing aids. In interview, the social services director stated she should have followed up on the status after documenting the progress note, and the nursing home administrator stated that after denial the facility was responsible for payment and replacement, but the process had not moved forward.
Failure to Address Ongoing Weight Loss and Poor Supplement Acceptance
Penalty
Summary
The facility failed to ensure one resident received nutritional care and services needed to maintain the highest practicable level of well-being. Resident #6 had diagnoses including type 2 diabetes, anemia, major depressive disorder, generalized muscle weakness, adult failure to thrive, chronic heart failure, a pressure ulcer, and protein-calorie malnutrition. The resident was cognitively intact, dependent on staff for most ADLs, and needed setup or cleanup assistance for eating. The MDS documented significant weight loss, and the resident was observed to be visibly emaciated during interview. Resident #6’s weight declined sharply over a short period, with documentation showing a loss from 133.0 lbs to 110.0 lbs in about one month and continued low weight thereafter. The care plan identified nutritional problems related to diabetes, malnutrition, and respiratory failure and included interventions such as ordered diet, meal intake monitoring, whole milk, snacks, and RD review. The resident had orders for Glucerna twice daily and protein oral liquid twice daily, but the MAR showed frequent refusals of both supplements across April, May, and early June. The record did not show documentation that the facility addressed the repeated refusals of the oral nutritional supplements. The resident also had documented food preferences that were not fully developed in the record. A dietary profile noted the dietary manager could not obtain answers about likes, dislikes, or allergies, and the record did not show additional attempts to assess preferences. The resident told staff he liked Spanish and Mexican food, coffee, milk, and certain supplement flavors, and he disliked chocolate-flavored supplements and the protein drink. Notes showed he often refused meals, snacks, Glucerna, and protein liquid, and he suspected staff were putting the protein liquid into his drinks. Although the dietitian recommended Megace for appetite stimulation, hospice would not cover it, and the facility did not implement a different nutritional intervention. Nutrition-at-risk notes later documented low meal intake and poor acceptance of supplements, but no new interventions were initiated despite the ongoing weight loss and poor intake.
Failure to Address Ongoing Suicidal Ideation and Trauma-Related Distress
Penalty
Summary
The facility failed to ensure that a resident with major depressive disorder, dementia, suicidal ideations, and a history of trauma received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The resident’s record showed severe cognitive impairment, frequent tearfulness, isolation in her room, refusal of medications and care, and repeated statements that she wanted to die or be with her husband in heaven. The resident also had a documented history of serious psychosocial stressors, including the death of her husband while she was hospitalized, prior suicide attempts, incarceration, loss of custody of her children, alcohol use, and distressing events identified on trauma screening. The record showed multiple statements and behaviors consistent with suicidal ideation before the suicidal ideation care plan was initiated during the survey process. After admission, the resident reportedly told a CNA she was going to commit suicide because she had no place to live, and later told nursing staff and social services that she wanted to die, would be better off dead, or was ready to die. She also made statements such as good, maybe she would just have a stroke and die when told about the importance of taking blood pressure medication. The resident continued to express grief, hopelessness, and distress about not knowing where family members were, while also refusing medications, refusing care, and isolating in her room. Although the facility had care plans addressing grief, mood and behavior, psychosocial well-being, and later suicidal ideation, the suicidal ideation care plan was not initiated until during the survey despite the resident’s history and ongoing statements. The record also showed that after some suicidal statements, the physician and social services director were not notified, and the social services director stated she had not put in a suicidal ideation care plan and had not performed a lethality assessment after the resident expressed suicidal ideation. Staff interviews confirmed the resident’s ongoing emotional distress, her trauma history, her resistance to care, and that conversation, music, snacks, and other informal approaches were used based on staff knowledge rather than a consistently documented person-centered plan.
Delayed Replacement of Lost Dentures
Penalty
Summary
The facility failed to ensure timely dental services for one resident whose dentures were lost and not replaced for an extended period. The resident was admitted with diagnoses including type 1 diabetes mellitus with hyperglycemia, age-related physical debility, and need for assistance with personal care. He was cognitively intact, had no natural teeth, and had previously received new dentures. After his dentures went missing in December 2025, he reported that he had placed them in a cup by his bed and they were gone the next morning. Record review showed the resident’s dental care plan documented the lost dentures and that he was in the process of getting new dentures, with insurance denials issued in December 2025 and again in February and March 2026. The social services notes showed the facility was pursuing payment through the PETI process, but the PETI form was not sent until 10 weeks after the January 2026 denial. During this time, the resident remained edentulous and continued to wait for replacement dentures. An emergency dental checklist documented pain rated 8 to 9 out of 10 with pressure sensitivity and swollen gums, and the resident stated his gums were sore and that he had difficulty eating what he wanted. Interviews confirmed the delay in follow-up. The social services director stated she should have followed up regularly on the denture replacement status. The nursing home administrator stated that once denial was received, the facility was responsible for paying for replacement dentures, but acknowledged that the matter had not been followed up and that the process had stalled. The registered dietitian stated that if a resident with missing dentures was still having trouble chewing and sore gums, the diet could have been changed to a softer texture, but she had not reviewed the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ordway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pioneer Health Care Center | 12.1 mi | ★★★★★ | 0 | 0 |
| Fowler Health Care | 15.9 mi | ★★★★★ | 11 | 0 |
| Bluestem Village | 27.7 mi | — | 0 | 0 |
| Bent County Healthcare Center | 30.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.