Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Diversicare Of Council Grove during CMS and state inspections, most recent first.
Staff failed to follow EBP and infection control practices during resident care and linen handling. Two CNAs provided hands-on care to a resident with open wounds without gowns, administrative nurses measured and photographed wounds with gowns not secured and without hand hygiene when changing gloves, and staff carried uncovered linens against uniforms and entered multiple rooms without hand hygiene between rooms.
Failure to designate a qualified IP for the IPCP. An interim nurse said she could not locate her IP certificate, had not really completed much of the IP duties, and was only enrolled in IP courses. Another admin staff member thought the interim nurse had a current IP certificate and expected the facility to have a designated certified IP. The facility did not provide an IP policy.
The facility failed to maintain an in-service training program for CNA staff with the required topics and at least 12 hours per year. Review of five staff files showed missing annual training hours, and several staff lacked required dementia education; one CMA also lacked training on abuse, neglect, and exploitation. Administrative Staff A stated that CNAs were expected to have the required training, and no staff training policy was provided.
Incomplete CAA Documentation for Comprehensive MDS Assessments: The facility failed to complete required CAA analysis of findings for multiple residents after comprehensive MDS assessments. Missing CAA documentation involved triggered areas such as functional abilities, cognition, communication, falls, nutrition, dehydration, pressure injury, psychotropic drug use, urinary incontinence, pain, and psychosocial well-being. Survey staff confirmed the comprehensive MDSs were completed offsite by an RN, but the CAA records lacked source documentation and individualized analysis of the collected data.
Medication Error Rate Exceeded 5 Percent: The facility had a 7.41% medication error rate after two errors were identified. A resident ordered acetaminophen and Refresh Tears received acetaminophen and artificial tears instead of the ordered eye drops, and the CMA reported giving the meds with the morning pass and not notifying an LN that they were late. The pharmacist confirmed the eye drops and artificial tears were not the same medication, and the regional RN stated meds should be given within one hour before or after the scheduled time.
Missing COVID-19 Vaccine Offer and Documentation: The facility failed to document that several residents were offered the COVID-19 vaccine or had informed declinations on file. EMR review showed no vaccine-offer documentation for multiple residents over several years, and staff could not confirm current consents or declinations. For staff, the COVID education materials reviewed during orientation covered COVID symptoms and masking, but did not include vaccine education or how to obtain the vaccine, despite verbal education being reported.
A resident left the facility against medical advice, but the EMR lacked documentation that the LTC Ombudsman was notified in writing of the discharge. In a separate case, another resident was discharged to the community, but the record lacked a discharge summary with a recap of the stay and medication reconciliation; staff stated nursing and social services were responsible for discharge documentation and planning.
Failure to provide ADL care and hygiene assistance: One resident with Parkinson’s disease, DM2, dysphagia, and polyneuropathy was scheduled for showers twice weekly but had no documented bath or shower for nearly two weeks and was observed with dirty clothing, skin flakes, messy hair, and facial stubble. Another resident with parkinsonism and Alzheimer’s disease, who required maximal assistance with personal hygiene, was repeatedly observed with dirty fingernails. Staff stated nails should be cleaned when dirty and checked daily, but the resident’s nails remained unclean.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Influenza vaccine consent and declination documentation was incomplete for two residents. One resident received the flu vaccine without documented education, and another resident declined the vaccine without documented education or a signed declination form. Administrative staff reported there were no current signed consents or declinations, and the facility policy required use of the Patient/Resident Declination/Authorization Form.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified through surveyor observation and record review.
A strong urine odor and unsanitary conditions were observed in a common area, where a resident was found sitting in a saturated recliner with wet clothing. Staff delayed cleaning the chair, and the area remained stained and odorous for hours. Family and staff reported ongoing issues with cleanliness and odor, and the facility could not provide a policy for maintaining a clean, comfortable environment.
A resident with severe cognitive impairment and incontinence was left in a urine-soaked recliner that was not promptly or properly disinfected, as housekeeping used only hot water without chemicals. In a separate incident, a nurse performed wound care on another resident without following required hand hygiene protocols, including failing to wash hands between glove changes and after removing personal protective equipment. These actions did not align with the facility's infection control policies.
Multiple rooms were found to have significant fly infestations, with one resident's wound care revealing live maggots. Staff acknowledged ongoing fly issues, limited and ineffective mitigation efforts, and the absence of a pest management policy.
A resident with intact cognition and a skin infection received a dressing change from a nurse who did not close the door or privacy curtain, leaving the resident exposed to the hallway. Facility policy required privacy during such care, but this was not followed, as confirmed by both the nurse and an administrative nurse.
A resident with multiple medical and behavioral diagnoses was issued a 30-day involuntary discharge without sufficient evidence in the clinical record to justify the action. Documentation did not show that the resident's needs could not be met or that others were endangered, and there was a lack of documented behavioral interventions or incident reports. Staff interviews confirmed the absence of physical aggression toward other residents, and the care plan lacked discharge planning prior to the notice.
The facility failed to submit accurate staffing data to CMS for four quarters, inaccurately reporting weekend staffing due to the omission of a salaried nurse's hours. The facility lacked a policy for completing the PBJ, and data submission was handled by the corporate office.
The facility failed to update care plans for residents with scabies and catheter management issues. A resident with dementia and vision loss had a scabies infection not reflected in their care plan. Another resident with severe cognitive impairment had catheter management issues, with tubing often on the floor and no alternatives for securing the catheter. A third resident lacked a care plan update for a leg bag and dignity cover, despite expressing a preference for privacy. Lastly, a resident with muscular dystrophy and a scabies infestation did not have an updated care plan or notification to their representative.
A facility failed to accommodate a resident with muscular dystrophy by not following up on recommendations for a new electric wheelchair. Despite an occupational therapy evaluation recommending a new wheelchair to improve posture and independence, the facility did not act on these recommendations. The resident's representative reported multiple attempts to contact the facility administrator without response, and the facility lacked documentation of any follow-up or communication regarding the wheelchair needs.
A resident with muscular dystrophy and a BIMS score of 15 was diagnosed with scabies, but the LTC facility failed to notify the resident's chosen representative about the new treatment plan. Despite the facility's policy requiring such notification, the representative was not informed, and the care plan was not updated, as confirmed by record reviews and staff interviews.
Two residents with severe cognitive impairment were observed with their urinary catheters exposed in public areas of the facility, violating their right to dignity. One resident's leg bag was visible without a dignity cover, and another resident's catheter tubing was exposed and unanchored. Staff confirmed the lack of appropriate covers and anchoring devices, despite facility policies emphasizing dignity and respect.
A resident with severe cognitive impairment and multiple medical conditions was not provided safe transfer techniques by staff, leading to a deficiency. The resident, who required substantial assistance, was initially instructed to transfer herself without the use of a gait belt or locked wheelchair brakes, contrary to standard safety practices.
A facility failed to provide proper catheter care for a resident with severe cognitive impairment, allowing catheter tubing to lie on the floor and lacking an anchoring device. Additionally, the facility did not analyze a resident's voiding diary to create a personalized toileting plan, leading to a fall. Staff were unaware of the resident's toileting plan, and the facility's fall prevention policy was not followed.
A resident with COPD and CHF received unsanitary respiratory care when a CMA failed to replace oxygen tubing and nebulizer components that fell on the floor. The CMA did not perform hand hygiene or wear gloves, contrary to facility policies. The resident, with severe cognitive impairment, required continuous oxygen and nebulizer treatments, highlighting the need for proper sanitary practices.
Two residents with constipation diagnoses did not receive necessary PRN medications for bowel movements, leading to prolonged periods without bowel movements. Despite having physician orders for laxatives, the facility lacked a standardized bowel protocol, resulting in inconsistent administration of medications. Staff interviews revealed uncertainty about bowel management procedures, contributing to the deficiency.
The facility did not maintain accurate daily staffing information for its 43 residents. Over a 90-day period, the actual hours worked by staff were not recorded on the Daily Staffing Sheets, which were posted each morning without updates. Administrative Nurse D confirmed the omission, and the facility lacked a policy for completing these sheets.
Failure to Use EBP, Perform Hand Hygiene, and Transport Linens Sanitarily
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions while providing direct care to a resident with open wounds on the left heel and left gluteal fold. On 07/07/2026, two CNAs transferred the resident with a mechanical lift and provided peri care while wearing gloves only, despite an EBP sign on the door and PPE available on the door. The CNAs confirmed they did not wear a gown as required for the care provided. The facility also failed to ensure adequate hand hygiene and sanitary linen handling. On 07/08/2026, two administrative nurses photographed and measured a resident’s wounds while their PPE gowns were not tied and kept falling off their shoulders during repositioning and while applying the disc marker near open wounds. One nurse removed and replaced gloves without performing hand hygiene, and the other removed a glove and applied a new one without hand hygiene while multiple open areas and serosanguineous drainage were present. In addition, a CNA was observed carrying uncovered washcloths and towels against her uniform in the hallway, and laundry staff carried personal linens against her uniform, entered multiple resident rooms, and did not perform hand hygiene between rooms while opening closets and removing hangers.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control to be responsible for the Infection Prevention and Control Program (IPCP). During interview, Administrative Nurse E, the interim nurse, stated she could not locate her IP certificate, said that when she accepted the interim position an IP certification was not mentioned, and reported that she had not really completed much of the IP duties at the facility. She also stated she was enrolled in courses for IP at the time. Later, she produced the antibiotic/infection control log binder. Record review showed a Completion for Nursing Home Infection Preventionist Training Course for Administrative Staff A, who stated she thought Administrative Nurse E had a current IP certificate and expected the facility to have a designated certified IP employed there. The facility did not provide a policy for an Infection Preventionist.
CNA In-Service Training Deficiencies
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff that included the required topics and at least 12 hours per year. Review of five CNA personnel files showed that CNA N, hired on 04/04/2007, lacked the total hours required for the 12-hour annual training. CMA T, hired on 12/20/2012, also lacked the total required hours and did not have education on abuse, neglect, exploitation, and dementia. CNA MM, hired on 03/25/2023, lacked the total required hours and did not have dementia training. CNA M, hired on 03/07/2024, lacked dementia training. CNA O, hired on 02/12/2025, lacked the total required hours and did not have dementia training. On 07/08/2026 at 10:00 AM, Administrative Staff A stated that she expected CNAs to have the required 12 hours and required training completed, and the facility did not provide a policy for staff training.
Incomplete CAA Documentation for Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis of findings for multiple residents after comprehensive MDS assessments were completed. The report identified missing CAA completion for residents including R2, R3, R4, R7, R25, R48, R49, and R52, with triggered care areas such as communication, functional abilities, psychosocial well-being, behavioral symptoms, activities, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer/injury, psychotropic drug use, urinary incontinence/indwelling catheter, cognitive loss/delirium, pain, dental care, and visual function left without the required analysis of findings. During the survey, Administrative Nurse E stated she was not aware of a nurse at the facility who completed the MDS assessments and referred the inquiry to Administrative Nurse D. Administrative Nurse D said she thought the MDS assessments were completed offsite and referred the inquiry to Consultant II. Consultant II confirmed the comprehensive MDS assessments were completed off-site by an RN responsible for the accuracy and completion of the MDSs, including the comprehensive assessment with the analysis of findings/CAAs. Consultant KK stated the facility used the RAI Manual for guidance and confirmed the CAA documentation for the named residents lacked source documentation showing the analysis of the collected data, beyond the narrative identifying where the triggering information was located.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent after two medication errors were identified, resulting in a 7.41 percent error rate. One error involved R22, whose physician orders included acetaminophen 325 mg, 2 tablets by mouth three times daily for chronic pain at 07:00 AM, 11:00 AM, and 05:00 PM, and Refresh Tears ophthalmic solution, 1 drop in both eyes three times daily for dry eye syndrome at 07:00 AM, 01:00 PM, and 08:00 PM. On 07/07/2026 at 09:03 AM, CMA R prepared R22's medications and reported that she administered the 07:00 AM medications with her other morning medications, stating she had always done it that way. She administered artificial tears, one drop in each eye, and acetaminophen at that time, and reported that she did not tell an LN that the medications were given late. Later that day, CMA R stated that R22 had always used artificial tears and did not have Refresh eye drops, and after reviewing the EMR and the label she reported the artificial tears were not the same ingredients as Refresh Tears. A medication substitution formulary had been requested the day before, but the facility did not provide one. The pharmacist reported that Refresh eye drops and the artificial tears administered were not the same medication, and both the pharmacist and the regional RN stated medications scheduled at a specific time were to be passed within one hour before or after the scheduled time. The regional RN also indicated that if a different medication was being used, the physician order would be changed.
Missing COVID-19 Vaccine Offer and Documentation
Penalty
Summary
The facility failed to offer and provide, or obtain an informed declination for, the COVID-19 vaccine for five residents: R5, R44, R8, R48, and R49. Record review showed that R5’s EMR lacked documentation of a COVID-19 vaccine being offered since 2021, R8’s EMR lacked documentation since 2023, and R44, R48, and R49 each lacked documentation of a COVID-19 vaccine being offered since 2024. Administrative Staff A stated she did not have current consents or declinations for the residents. For staff vaccination education, Administrative Staff A reported she was unsure whether the facility offered COVID-19 vaccine education to staff. Consultant Staff HH stated that new hires received COVID education during orientation and were offered the vaccine through their own provider or through the facility if they could not receive it elsewhere. However, the PowerPoint used for COVID education only covered what COVID was, symptoms, and masking or staying home, and it did not include education about the COVID-19 vaccine or how to obtain one. Consultant Staff HH stated that vaccine education was completed verbally during the education.
Missing Ombudsman Notification and Discharge Summary Documentation
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman in writing of Resident 53’s discharge from the facility. Resident 53’s records showed admission to the facility and a discharge return not anticipated MDS dated 05/07/2026 documenting discharge to the community on 05/07/2026. A social service progress note on 05/07/2026 at 1:30 PM stated the resident did not want to stay at the facility and left against medical advice, but the EMR lacked documentation that the Ombudsman was notified of the discharge. The facility was unable to provide such documentation when requested, and administrative staff confirmed the facility had not been notifying the Ombudsman of resident discharges prior to the survey. The facility also failed to complete a discharge summary for Resident 6 that included a recapitulation of the resident’s stay and/or reconciliation of medications after discharge. Resident 6’s admission MDS documented admission to the facility, and a progress note dated 06/29/2026 recorded discharge orders received for discharge to the community. However, the EMR lacked a discharge summary addressing the resident’s stay or medication reconciliation. Staff interviews indicated that nursing staff should ensure discharge orders, complete a discharge assessment to recap the resident’s stay, reconcile medications, and document medication disposition, while social services should open the discharge evaluation and set up the discharge plan. Administrative staff confirmed the record lacked the required discharge summary information.
Failure to Provide ADL Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary care and services for activities of daily living for two residents. One resident had diagnoses including left femur fracture/displacement, Parkinson’s disease, diabetes mellitus type II, dysphagia, and polyneuropathy, and his care plan and CAA directed staff to provide substantial to moderate assistance with eating, showering, and shower room transfers. Although shower days were scheduled for Tuesday morning and Friday evening, the shower book contained no completed shower sheets for him, and the EHR had no documented evidence that he received a bath or shower between 06/19/2026 and 07/03/2026. During observation, he was seen wearing dirty clothing and socks, with skin flakes on his sweatshirt, messy hair, and stubble on his face. He stated he had not received a shower for almost two weeks and said he likes to be clean-shaven. Another resident had diagnoses of parkinsonism and Alzheimer’s disease, with severely impaired cognition documented on MDS assessments and care planned for maximal assistance with personal hygiene. On multiple observations, her fingernails had a brown substance under them while she sat in her wheelchair in common areas and the dining room. Staff interviews stated that dirty or unclipped nails should be cleaned when seen, especially on shower day, and that nails should be checked every morning, but the resident’s nails remained dirty during the observations. The facility did not provide a policy for activities of daily living for a dependent resident.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
Influenza Vaccine Consent and Declination Documentation
Penalty
Summary
The facility failed to offer and provide, or obtain an informed declination for, influenza vaccination for two residents. Resident 5's EMR documented that no education was provided when she received the influenza vaccine, although consent was documented as confirmed. Resident 8's EMR documented that no education was provided when he declined the influenza vaccine, and the facility was unable to provide a signed Patient/Resident Declination/Authorization Form for the flu vaccine. During interview, Administrative Staff A provided a handwritten list of residents, a copy of the influenza vaccine sticker showing the lot number, expiration date, and administration site, and reported that there were no current signed consents or declinations for the residents' influenza vaccines. Administrative Staff A also reviewed the EMR and stated that the nurse should have documented yes for education when administering the vaccine or when the resident refused. The facility policy stated that consent or declination for the influenza vaccine would be obtained and documented using the Patient/Resident Declination/Authorization Form, and that information regarding influenza and the influenza vaccine would be discussed with the resident and/or responsible party.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. The report does not specify the exact nature of the treatment or care that was not provided, nor does it detail the resident’s medical history or condition at the time of the deficiency.
Failure to Maintain Clean and Homelike Environment in Common Area
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in the common living area, as evidenced by multiple observations of strong urine odors and unsanitary conditions. Upon entering the facility, a strong odor of urine was detected, particularly in the A-Hall unit. A resident was observed sitting in a recliner with visibly wet pants and a saturated chair, both emitting a strong urine smell. Certified Nurse Aides used a sit-to-stand lift to assist the resident, confirming the saturation of both the resident and the recliner. Despite requests to housekeeping, the chair remained uncleaned for an extended period, and when it was eventually shampooed, it remained wet and stained hours later. Family members and staff corroborated the presence of persistent urine odors and noted a decline in cleanliness over the past several months. Staff reported using odor-masking sprays to address the smell. The facility was unable to provide a policy related to maintaining a clean, safe, and comfortable home-like environment for residents.
Infection Control Deficiencies: Inadequate Hand Hygiene and Improper Cleaning of Soiled Furniture
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inadequate hand hygiene during wound care and improper cleaning of soiled furniture. One resident with severe cognitive impairment, a history of urinary tract infections, and total incontinence was observed sitting in a fabric recliner that was saturated with urine. Certified Nurse Aides transferred the resident to be cleaned and changed but did not immediately clean or disinfect the soiled chair. Housekeeping later cleaned the chair using only hot water in a shampooer, without any disinfectant chemicals, and the chair remained visibly stained and wet for several hours. Staff interviews revealed inconsistent understanding and application of cleaning protocols, with some staff believing hot water alone was sufficient and others stating that soiled cloth chairs should be discarded or disinfected with germicidal wipes. Additionally, a licensed nurse was observed performing wound care on another resident without following proper hand hygiene protocols. The nurse donned gloves and a gown without performing hand hygiene, removed and cleaned wounds, and changed gloves multiple times without washing hands between glove changes or before applying clean dressings. The nurse also removed personal protective equipment in the incorrect order and failed to perform hand hygiene at required points during the procedure. The nurse later acknowledged these lapses and described the correct procedures, which were not followed during the observed care. Facility policies required maintaining a safe, sanitary, and comfortable environment to prevent and manage the transmission of infections. However, observations and staff interviews demonstrated that these policies were not consistently implemented, resulting in practices that could contribute to the spread of infection among residents.
Failure to Implement Effective Pest Control Measures
Penalty
Summary
The facility failed to ensure effective pest control, as evidenced by multiple observations of a significant fly infestation in the rooms of two residents. On several occasions throughout the day, large numbers of flies were observed in these rooms, with one room displaying a fly paper strip as the only visible mitigation effort, while the other room showed no evidence of any fly control measures. During wound care for one resident, live maggots were found in a lower leg wound. Facility staff acknowledged ongoing concerns about flies, identified certain rooms as problem areas, and noted that fly paper strips had been ineffective. Although fly bags had been ordered and received, they had not yet been installed. The facility was unable to provide a policy related to pest management.
Failure to Provide Privacy During Personal Care
Penalty
Summary
A deficiency occurred when a licensed nurse entered a resident's room to perform a dressing change without providing privacy. The nurse did not close the door or pull the privacy curtain, leaving the resident visible from the hallway during the procedure. The resident involved had a diagnosis of local skin infection and an unspecified adult personality disorder, with documentation indicating intact cognition. The facility's policy required staff to inform residents about care and ensure privacy by shutting the door and pulling the curtain, but this was not followed during the observed event. Both the nurse and an administrative nurse confirmed that privacy should have been provided during personal care.
Involuntary Discharge Without Sufficient Documentation or Interventions
Penalty
Summary
The facility initiated a 30-day involuntary discharge for a resident with multiple complex diagnoses, including schizoaffective disorder, diabetes mellitus type 2, heart failure, visual loss, personality and behavioral disorders, and alcohol abuse. The resident's clinical record documented behavioral symptoms such as verbal outbursts, accusations, and occasional refusal of care, but there was no evidence in the record to validate the reason for the involuntary discharge. Specifically, the clinical documentation did not show that the resident's needs could not be met at the facility or that the resident had placed other residents in danger, which are required justifications for involuntary discharge. Throughout the review period, progress notes described the resident as having episodes of yelling, cursing, and making accusations against staff and other residents, as well as some physical actions like throwing a shoe and rolling a wheelchair into staff. However, the records consistently lacked documentation of interventions attempted to address these behaviors, and there were no investigative or incident reports regarding alleged inappropriate behaviors toward other residents. Staff interviews confirmed that while the resident was verbally aggressive and irritable, there were no known physical altercations with other residents, and all aggressive behaviors were primarily directed at staff. One administrative staff member reported a threat made by the resident toward another resident, but this was not recognized or reported as resident-to-resident abuse, and no incident report was filed. The care plan for the resident did not include discharge planning interventions prior to the issuance of the involuntary discharge notice. Additionally, the facility was unable to provide a policy related to involuntary discharge. The lack of documentation supporting the necessity of the involuntary discharge, absence of evidence that the resident's needs could not be met, and failure to document or attempt behavioral interventions led to the deficiency. The facility's actions did not demonstrate that the transfer or discharge met the resident's needs or preferences, nor that the resident was prepared for a safe transfer or discharge.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for four consecutive quarters. The deficiency was identified through observation, interview, and record review, revealing that the facility did not accurately report weekend staffing on the Payroll Base Journal (PBJ). Despite the facility's daily staffing sheets indicating that weekend staffing was the same as weekdays, the PBJ data showed excessively low weekend staffing. This discrepancy was partly due to the omission of hours worked by a salaried employee, Administrative Nurse D, whose hours were not recorded on the facility timesheet. The facility lacked a policy regarding the completion of the PBJ, and the responsibility for submitting the data to CMS was delegated to the corporate office.
Failure to Update Care Plans for Residents with Scabies and Catheter Management Issues
Penalty
Summary
The facility failed to review and revise care plans for four residents, leading to deficiencies in addressing their medical needs. Resident 8, diagnosed with dementia and vision loss, exhibited symptoms of scabies, but the care plan was not updated to reflect this condition or the treatment prescribed by the physician. Despite two rounds of treatment with Permethrin cream, the care plan remained unchanged, contrary to the facility's policy requiring updates based on resident status. Resident 19, with severe cognitive impairment and an indwelling urinary catheter, had issues with catheter management. Observations revealed the catheter tubing frequently lay on the floor, and the resident often removed the anchoring device. The care plan did not include alternatives for securing the catheter or address the resident's behavior of removing the device, which was necessary to maintain catheter hygiene and proper positioning. Resident 41, also with severe cognitive impairment and an indwelling catheter, lacked a care plan update to include the use of a leg bag and a dignity cover. The resident expressed a preference for privacy regarding the visibility of the catheter bag, but the facility did not provide a dignity cover. Similarly, Resident 18, with muscular dystrophy and a scabies infestation, did not have an updated care plan to reflect the new diagnosis and treatment, nor was there documentation of notifying the resident's representative about the change in condition.
Failure to Accommodate Resident's Wheelchair Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs of Resident 18, who has muscular dystrophy, contractures, and is paraplegic, by not following up on recommendations for a new electric wheelchair. The resident's current wheelchair was donated years ago and was no longer suitable, as it contributed to poor positioning and increased the risk of contractures. Despite an occupational therapy evaluation in March 2023 recommending a new wheelchair to maximize the resident's posture and independence, the facility did not act on these recommendations. The resident's medical records from March 2023 to August 2024 lacked documentation of any follow-up on the wheelchair assessment and recommendations. The resident's representative reported multiple attempts to contact the facility administrator regarding the wheelchair, but received no response. The facility's administrative staff confirmed that the recommendations were forwarded to the corporate office, but there was no documentation of any decision or communication with the resident's representative. The resident expressed concerns about the deteriorating condition of his current wheelchair and the lack of communication from the facility. The therapy consultant reiterated the need for a new wheelchair to prevent further decline in the resident's condition. The facility did not have a policy in place to address reasonable accommodation of identified needs for residents, leading to a failure in meeting the resident's needs for a suitable wheelchair.
Failure to Notify Resident's Representative of New Treatment
Penalty
Summary
The facility failed to notify a resident's chosen representative when the resident required a new form of treatment for a newly diagnosed scabies infestation. The resident, who was cognitively intact with a BIMS score of 15, had a history of muscular dystrophy, contractures, immobility syndrome, and anxiety disorder. Despite the resident's clear preference for family involvement in care discussions, the facility did not inform the representative about the change in condition or the new treatment order for Permethrin cream to address the scabies infestation. The deficiency was identified through a review of the resident's records, which showed a lack of documentation indicating that the representative was notified of the condition change and treatment plan. Observations confirmed the resident was receiving treatment for scabies, and interviews with staff and the resident further revealed the oversight. The facility's policy required notification of the resident's representative in such cases, but this protocol was not followed, and the resident's care plan was not updated to reflect the new treatment.
Failure to Maintain Resident Dignity with Urinary Catheter Management
Penalty
Summary
The facility failed to maintain the dignity of two residents by not adequately covering their indwelling urinary catheters while they were in public areas. Resident 41, who has severe cognitive impairment and requires substantial assistance with toileting, was observed multiple times in the dining room and common areas with his urinary catheter leg bag visible to others. The facility did not provide a dignity cover for the leg bag, despite the resident expressing a preference for it to be concealed. Staff members confirmed the absence of appropriate covers for the leg bags, and the facility's policy emphasized the importance of treating residents with dignity and respect. Resident 19, who also has severe cognitive impairment and multiple medical conditions, was observed in the dining room with her urinary catheter tubing exposed and lying on the floor. The resident, who uses a wheelchair and requires assistance for transfers, did not have a lap robe to cover her exposed thighs, and the catheter tubing was not anchored properly. Staff noted that the resident often removed the anchoring device, but no alternative solutions were in place to ensure her dignity was maintained in public areas. The facility's failure to provide dignity covers and proper anchoring for urinary catheters resulted in the residents being exposed in common areas, contrary to the facility's policy on resident rights. The observations and interviews with staff highlighted a lack of resources and procedures to protect the residents' dignity, as required by the facility's own guidelines.
Failure to Ensure Safe Transfer Techniques for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure safe transfer techniques for a resident, identified as R19, who was at risk for falls due to severe cognitive impairment and multiple medical conditions, including a cerebral vascular accident, osteoarthritis, chronic obstructive pulmonary disease, and neurogenic bladder. The resident required substantial to maximal assistance for transfers and had a history of falls. Despite these needs, a Certified Nurse Aide (CNA) instructed the resident to transfer herself from her wheelchair to her bed without initially locking the wheelchair brakes or using a gait belt, which are standard safety practices. During the observed transfer, the resident struggled to stand and pivot into bed, requiring eventual assistance from the CNA who then used a gait belt. Additionally, the resident's water cup was placed on the floor, out of reach, which could have led to overreaching and potential falls. The facility's policy on falls prevention required staff to identify interventions to prevent falls, but these were not adequately implemented in this instance, leading to a deficiency in providing safe transfer techniques for the resident.
Deficiencies in Catheter Care and Toileting Plan
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with severe cognitive impairment and multiple medical conditions, including a history of urinary tract infections. Observations revealed that the resident's urinary catheter tubing was frequently found lying directly on the floor, and the resident lacked an anchoring device for the catheter. Despite the resident's tendency to remove the anchoring device, staff did not ensure the tubing was kept off the floor, and the facility did not provide a skills checklist for catheter care. Another deficiency involved the facility's failure to analyze a three-day voiding diary for a resident with stress incontinence and severe cognitive impairment. The resident experienced frequent incontinence episodes, but the facility did not interpret the voiding pattern data to develop a personalized toileting plan. This lack of analysis contributed to the resident's fall while attempting to reach the bathroom independently. Interviews with staff revealed a lack of awareness regarding the resident's toileting plan, and the facility's fall prevention policy was not adequately followed. The facility did not evaluate a toileting schedule for the resident, which was a contributing factor to the resident's fall and the failure to address the resident's toileting needs effectively.
Unsanitary Respiratory Care for Resident with COPD and CHF
Penalty
Summary
The facility failed to provide sanitary respiratory care for a resident with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The resident, who had severe cognitive impairment, required continuous oxygen via nasal cannula and nebulizer treatments with ipratropium-albuterol. During an observation, a Certified Medication Aide (CMA) was seen handling the resident's oxygen tubing and nebulizer components in an unsanitary manner. The oxygen tubing cannula was found lying on the floor, and the CMA attempted to clean it with a wet paper towel instead of replacing it. Additionally, the CMA did not perform hand hygiene or wear gloves while handling the nebulizer components, which were also dropped on the floor and inadequately rinsed before being returned to the storage container. The facility's policies on oxygen and nebulizer guidelines, which align with the Center for Disease Control Guidelines for Preventing Healthcare-Associated Pneumonia, were not followed. The Administrative Nurse confirmed that the standard practice would require replacing the oxygen cannula, tubing, and nebulizer components if they fell on the floor, and that staff should perform hand hygiene and wear gloves during such procedures. The failure to adhere to these guidelines resulted in unsanitary respiratory care for the resident, who had a compromised respiratory system.
Failure to Administer PRN Medications for Constipation
Penalty
Summary
The facility failed to ensure that two residents, R12 and R27, remained free from unnecessary medications related to the administration of PRN medications for bowel movements. Resident 12, who had a diagnosis of constipation and required extensive assistance for transfers and toileting, did not have a bowel movement for five days. Despite the care plan indicating the need for PRN bowel medication, the resident's Medication Administration Record showed no PRN medications available for constipation. Interviews revealed that the facility lacked a specific bowel protocol, and the resident confirmed experiencing constipation without receiving medication. Similarly, Resident 27, who also had a diagnosis of constipation and required substantial assistance for toileting, did not have a bowel movement for four days. The resident had physician orders for various laxatives, but reported inconsistent administration of these medications by the nursing staff. Interviews with staff indicated that while the computer system alerted nurses to residents who had not had a bowel movement in three days, there was no consistent protocol for addressing constipation, and the facility lacked a policy regarding bowel movements. The deficiency was further highlighted by the lack of a standardized bowel protocol and the absence of standing orders for bowel management. Both residents experienced prolonged periods without bowel movements, and the facility's failure to administer PRN medications as needed contributed to this issue. Staff interviews revealed uncertainty about the facility's bowel management procedures, indicating a systemic issue in addressing residents' constipation needs.
Failure to Maintain Accurate Daily Staffing Information
Penalty
Summary
The facility failed to display accurate and publicly accessible staffing information on a daily basis for its 43 residents. Upon review of the facility's Daily Staffing Sheets over the past 90 days, it was found that the actual hours worked by staff were not recorded on these sheets. The staffing sheets were completed and posted each morning without any updates or changes to reflect the actual hours worked. An interview with Administrative Nurse D confirmed that the facility did not include actual hours worked on the daily staffing sheets. Additionally, the facility lacked a policy for the completion of these daily staffing sheets, contributing to the deficiency in maintaining accurate staffing records.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Council Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chase County Care And Rehab | 20.5 mi | ★★★★★ | 0 | 0 |
| Holiday Resort | 22.1 mi | — | 0 | 0 |
| Emporia Presbyterian Manor | 22.5 mi | ★★★★★ | 16 | 0 |
| Flint Hills Care And Rehabilitation Center | 23 mi | ★★★★★ | 0 | 0 |
| Legacy At Herington | 23.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.