Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Frankfort Community Care Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a known risk for wandering exited the facility unsupervised after staff failed to respond promptly to a door alarm. The resident traveled in a wheelchair across the driveway and into the street before being retrieved by staff, despite care plan interventions and facility policy requiring immediate response to such incidents.
The facility did not ensure that the Medical Director attended all required quarterly QAA Committee meetings, with documentation showing only three meetings held in the year and a six-month gap between two meetings. Administrative staff confirmed the absence of both required quarterly meetings and the Medical Director at some meetings, contrary to facility policy.
Staff did not follow enhanced barrier precautions during wound care for a resident with a draining ankle wound. During a dressing change, only gloves were used, and a gown was not worn as required by facility policy for high-contact care activities involving wounds. Both a nurse and an administrative nurse later confirmed that enhanced barrier precautions should have been in place.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for its 27 residents. Instead, a recently hired dietary staff member without certification or ongoing training was responsible for meal preparation and distribution, contrary to facility policy requiring a certified dietary manager in the absence of a full-time dietitian.
Kitchen staff did not consistently obtain or document food temperatures before serving meals, including ground pork chop, to residents. Meals were plated and served without verifying that food was at a safe temperature, and the omission was only corrected after prompting, with the ground pork chop found at 105°F, below the required hot holding temperature.
The facility did not consistently document daily temperatures for freezers, refrigerators, and food, nor did it reliably record sanitizer PPM levels for sinks and buckets, as required by policy. Dietary staff acknowledged ongoing issues with staff compliance in these areas, leading to lapses in food safety monitoring and documentation.
A resident was not given the required CMS Form 10123 (ABN) when Medicare-covered skilled services were ending. Staff interviews and record review confirmed the notice was not provided or documented, despite facility policy requiring advance notification to inform the resident of potential financial liability and appeal rights.
Two residents were transferred to the hospital without timely notification to the Long-Term Care Ombudsman, and one did not receive written information about the facility's bed hold policy as required by facility policy. Staff interviews confirmed that notifications were either delayed or missed, and documentation was lacking in the clinical records.
Two residents did not have comprehensive care plans addressing all of their needs. One resident with lymphedema lacked care plan documentation and staff guidance for compression garment use, despite physician orders and frequent refusals. Another resident with PTSD and depression had a care plan that did not include trauma-based triggers or individualized interventions for PTSD, even though psychiatric evaluations documented ongoing symptoms. Facility policies required person-centered, trauma-informed care plans, but these were not implemented for the affected residents.
Staff did not properly store a resident's nebulizer mask and oxygen tubing as required, leaving them uncovered on equipment instead of in designated bags, despite physician orders and facility policy. The resident, who had COPD and required regular respiratory treatments, confirmed that staff usually placed the items in separate bags, but this was not consistently done.
A resident with PTSD and MDD did not have trauma-based triggers or individualized interventions documented in their care plan, despite behavioral health notes indicating ongoing symptoms. The care plan only addressed depression related to a stroke, and staff confirmed the omission of PTSD-related information, which was required by facility policy.
A resident with orthostatic hypotension and other conditions received midodrine for low blood pressure on multiple occasions when their blood pressure readings were above the physician-ordered parameters. The MAR showed repeated administration of the medication outside of prescribed limits, and staff confirmed that the medication was not held as ordered.
A resident's insulin flex pen was found on the medication cart without the required opened and expiration dates. Both an LPN and an administrative nurse confirmed that nursing staff are responsible for labeling insulin pens when opened, in accordance with facility policy and professional standards.
A resident with a terminal prognosis and multiple chronic conditions was admitted to hospice care, but the facility failed to include specific hospice service details in the care plan or coordinate care with the hospice provider as required. Staff confirmed the absence of a coordinated care plan, resulting in a deficiency related to the lack of documented collaboration and communication with hospice.
A resident with dementia and severe cognitive impairment was not adequately protected from intimidation and potential abuse by a nurse. The nurse was reported to have forcefully pulled the resident into a chair and made derogatory comments about dementia patients. Despite the facility's investigation not substantiating the abuse allegation, the nurse's actions and comments indicated a lack of understanding of dementia care, placing the resident at risk for impaired psychosocial well-being.
A cognitively impaired resident with a history of exit-seeking behavior and identified as high risk for elopement managed to exit through a window without setting off the alarm, despite wearing a Wander Guard bracelet. The resident's care plan included interventions to distract from wandering and identify behavior patterns, but these measures were insufficient. The window lacked proper security measures, such as a missing screen, which facilitated the elopement. The incident highlighted gaps in supervision protocols and environmental safeguards for residents with cognitive impairments and elopement risks.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A cognitively impaired resident with diagnoses including subarachnoid hemorrhage, dementia, anxiety, and insomnia, and who was identified as high risk for wandering, exited the facility unsupervised. The resident, who used a wheelchair and wore a Wander Guard, was able to open a delayed-egress door that alarmed upon activation. Despite the alarm sounding, no staff responded immediately. The resident propelled herself across the driveway and into the city street, traveling approximately 200 feet before being noticed by staff. At the time of the incident, the nurse on duty heard the alarm and saw the resident exiting but did not immediately respond to the door. Instead, the nurse returned to the nurse's station and only later proceeded down the hall, at which point the resident was already outside in the street. The nurse called for assistance, and a CNA responded, retrieving the resident and bringing her back inside. The facility's video footage confirmed that the resident was outside unattended for approximately three minutes and that the nurse did not maintain continuous visual observation of the resident during the elopement. The resident's care plan documented her as an elopement risk and included interventions such as structured activities, reorientation strategies, and signage on facility doors. However, the care plan was not effectively implemented, as staff failed to respond promptly to the door alarm and did not prevent the resident from leaving the premises. The facility's policy required immediate response to alarms and supervision of residents at risk for elopement, but these procedures were not followed, resulting in the resident's unsupervised exit.
Removal Plan
- Immediate 1:1 supervision with behavior monitoring were initiated for R7.
- Nursing counseling was provided to LN H and her supervisor on the facility's Elopement and Wandering policy.
- Facility-wide education was implemented regarding the immediate retrieval of a resident during an exit attempt in conjunction with a review of the elopement policy.
- Plan of care meetings were held with R7's family.
- A Behavior Monitoring log was initiated to assess for exit-seeking behaviors, restlessness, or patterns warranting intervention.
- The facility pharmacy consultant performed a focused medication review related to the resident's increased exit seeking to find family, brief recall of direction, and intermittent agitation.
- Administration contacted their door lock company to assess and repair any issues identified.
- The Director of Nursing submitted a report to the Kansas State Board of Nursing regarding LN H's failure to communicate that she did not have eyes on R7 the entire time of the elopement.
Failure to Hold Quarterly QAA Meetings with Medical Director Attendance
Penalty
Summary
The facility failed to ensure that its Medical Director attended all required quarterly Quality Assessment and Assurance (QAA) Committee meetings. Documentation provided by the facility showed that QAA meetings were held on three occasions within the year, but there was a six-month gap between two of the meetings, and only three out of four required quarterly meetings were documented. Additionally, the Medical Director was absent from one of the documented meetings. Administrative staff confirmed that QAA meetings should be held quarterly and that the Medical Director is required to attend, verifying both the lack of quarterly meetings and the Medical Director's absence at some meetings. The facility's policy states that the QAA committee, which includes the Medical Director among other key staff, is responsible for overseeing and implementing the quality assurance and performance improvement program. The committee is required to meet at least quarterly to fulfill its responsibilities, which include analyzing performance data, identifying and resolving care quality problems, and communicating findings to the administrator and governing body. The failure to hold quarterly meetings and ensure the Medical Director's attendance represents a deviation from both regulatory requirements and the facility's own policy.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) during wound care for a resident with a right outer ankle wound that exhibited green drainage. During the dressing change, a licensed nurse and a consultant entered the resident's room, donned gloves, and proceeded with the wound care procedure, including removing the old dressing, cleansing the wound, and applying a new dressing. At no point during the high-contact care activity did staff utilize both gloves and gowns as required by the facility's EBP policy for residents with wounds, nor was the resident placed on EBP at the time of care. Both the licensed nurse and the administrative nurse later acknowledged that the resident should have been on EBP, in accordance with the facility's policy, which mandates gown and glove use for high-contact care activities involving residents with wounds. The policy specifically lists wound care as an activity requiring EBP, but this protocol was not followed during the observed dressing change, resulting in a failure to ensure a sanitary environment and prevent the potential transmission of communicable diseases.
Lack of Certified Dietary Manager for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager to oversee food and nutrition services for its 27 residents. Observations showed that a dietary staff member, who had only recently started working at the facility, was responsible for meal preparation and distribution but was not certified and had not begun certification classes. Interviews with staff confirmed that this individual lacked the required certification. The facility's own policy requires that, in the absence of a full-time dietitian, a certified dietary manager must be designated to oversee food and nutrition services, but this standard was not met.
Failure to Obtain and Document Food Temperatures Prior to Meal Service
Penalty
Summary
Kitchen staff failed to consistently take and document food temperatures before serving the noon meal to residents. During meal preparation, a dietary staff member ground pork chops and placed them in a steam table, then served plates to three residents without obtaining or recording the food temperatures. When questioned, the staff member stated that temperatures had been taken earlier but not documented, and subsequently took temperatures of the main and pureed meals, but not the ground pork chop. The staff member then plated meals for two residents with ground pork chop without checking the temperature, only doing so after being reminded, at which point the ground pork chop measured 105 degrees Fahrenheit. Facility policy requires staff to verify food temperatures to prevent foodborne illness, maintaining hot foods at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. The dietary staff member acknowledged forgetting to check the temperature of the ground meat before serving it. Another dietary staff member confirmed that food temperatures should be checked before serving and noted ongoing efforts to improve compliance with this requirement.
Failure to Consistently Document Food Storage and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety, as evidenced by multiple instances of incomplete documentation and monitoring. During a kitchen tour, it was observed that daily temperature logs for seven freezers and three refrigerators were missing numerous entries for both morning and evening checks throughout the month. Additionally, the daily sink and bucket sanitizer PPM logs lacked documentation for a significant number of opportunities, indicating that the concentration of sanitizing solutions was not consistently monitored or recorded. The daily food temperature logs also showed multiple days where meal temperatures were not documented for breakfast, lunch, or dinner. Dietary staff confirmed ongoing issues with staff compliance in recording required temperatures for freezers and meals. The facility's own policy required daily checks and documentation of refrigerator and freezer temperatures upon first opening and at closing, as well as proper sanitation practices. Despite these requirements, the facility did not ensure consistent adherence to its policies, resulting in lapses in food safety monitoring and documentation.
Failure to Provide Required Medicare Advance Beneficiary Notice
Penalty
Summary
The facility failed to provide the required CMS Form 10123, Advanced Beneficiary Notice (ABN), to a resident or their representative when Medicare-covered skilled services were ending. Record review and staff interviews confirmed that the ABN, which informs beneficiaries about potential non-coverage and their financial liability, was not given to the resident when their skilled services ended. The form is intended to allow residents to make informed decisions about continuing services and to appeal Medicare decisions, but there was no documentation that the resident or their representative received this notice. Administrative staff interviews revealed that responsibility for issuing the ABN was assigned, but the required documentation could not be located, and staff confirmed the form was not provided. The facility's own policy required that the ABN be issued at least two calendar days before the end of Medicare-covered services, but this procedure was not followed, resulting in the deficiency.
Failure to Notify Ombudsman and Provide Bed Hold Policy Information During Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman regarding the hospital transfers of two residents. For one resident with diagnoses including orthostatic hypotension, vertigo, depression, and a left artificial hip joint, the clinical record showed a hospital admission for a left hip hemiarthroplasty. There was no evidence in the electronic medical record or nurse's notes that the Ombudsman was notified of this transfer, and staff interviews confirmed that notification was not completed at the time of transfer, but rather was typically done at the end of the month. Another resident, with diagnoses of schizophrenia, diabetes mellitus type 2, chronic pain, left lower extremity amputation, and dementia, was transferred to the hospital for a scheduled amputation. The clinical record lacked documentation that the resident or their family received written notification of the facility's bed hold policy prior to transfer, and there was also no evidence that the Ombudsman was notified of the transfer. Staff interviews confirmed that the bed hold notification was not provided and that Ombudsman notification was missed. Facility policies required that residents and/or their representatives be notified in writing of impending transfers or discharges, including the reasons for the move, and that a copy of the notice be sent to the Ombudsman. Policies also required that written information about bed hold policies be provided to residents or their representatives at the time of transfer. These requirements were not met for the two residents in question, as documented in the clinical records and confirmed by staff.
Failure to Develop Comprehensive, Individualized Care Plans for Residents with Lymphedema and PTSD
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific medical and psychological needs. For one resident diagnosed with lymphedema, the care plan did not include documentation of the condition or provide staff with directions regarding the use of a prescribed compression glove and wrap. Although the physician's order specified how and when to apply the compression garments, and staff were aware of the resident's frequent refusals and discomfort, this information was not reflected in the care plan. Observations and staff interviews confirmed that the resident often refused the compression garments, and staff continued to report refusals to the physician, but the care plan was not updated to guide staff actions or document refusals appropriately. Another resident with diagnoses of posttraumatic stress disorder (PTSD), major depressive disorder, and diabetes mellitus had a care plan that addressed depression but did not include individualized interventions or triggers related to PTSD. The psychiatric evaluation documented the resident experienced intrusive thoughts, flashbacks, and anxiety related to military trauma, and was prescribed medication intended to address both depression and PTSD symptoms. However, the care plan lacked any mention of trauma-based triggers or specific strategies for staff to support the resident in managing PTSD symptoms, despite facility policy requiring trauma-informed, individualized care planning. Facility policies required comprehensive, person-centered care plans that address all resident needs, including measurable objectives and timetables, and specifically called for trauma-informed care planning. The deficiencies were identified through record review, staff interviews, and direct observation, revealing that the care plans did not reflect current standards of practice or the individualized needs of the residents as required by facility policy.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
Staff failed to provide necessary respiratory care and services for a resident with chronic obstructive pulmonary disease (COPD), diabetes mellitus, depression, and anxiety. The resident was independent in daily activities and required supplemental oxygen and nebulizer treatments as ordered by the physician. Observations revealed that the nebulizer mask was repeatedly left uncovered on top of the nebulizer machine, and the oxygen tubing and nasal cannula were wound up and placed uncovered between the oxygen concentrator handle and machine, rather than being stored in the designated fabric bags as required by facility policy and physician orders. Interviews with the resident, a licensed nurse, and an administrative nurse confirmed that the proper procedure was to store the oxygen tubing and nebulizer mask in fabric bags when not in use. The facility's infection prevention policy also directed staff to keep these items in labeled plastic bags between uses. Despite these directives, staff did not consistently follow the required storage protocols, resulting in a failure to provide safe and appropriate respiratory care for the resident.
Failure to Identify and Address Trauma-Based Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and address trauma-based triggers for a resident diagnosed with posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). The resident's electronic medical record documented these diagnoses, and the care plan only addressed depression related to a stroke, with no mention of PTSD triggers or individualized interventions. Despite behavioral health notes indicating the resident experienced intrusive thoughts and flashbacks related to military service, as well as difficulty sleeping and anxiety, the care plan did not include strategies to prevent re-traumatization or address the resident's PTSD. Observations and interviews confirmed that the care plan lacked documentation of trauma-based triggers and individualized interventions for PTSD. The facility's policy required trauma-informed and culturally competent care, including universal screening for trauma exposure and individualized care planning in collaboration with residents and families. However, the care plan for this resident did not reflect these requirements, and staff acknowledged the omission after review. The deficiency was identified through observation, record review, and staff interviews.
Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
The facility failed to follow physician-ordered parameters for administering blood pressure medication to a resident diagnosed with orthostatic hypotension, vertigo, depression, and nonrheumatic aortic valve stenosis. The physician's order specified that midodrine should be held if the resident's blood pressure exceeded 140/85 mmHg. However, the Medication Administration Records (MAR) for July, August, and September documented multiple instances where the resident received midodrine despite blood pressure readings above the ordered threshold. These instances were confirmed by a licensed nurse, who verified that the medication was not held as directed by the physician's order. The resident's care plan identified her as being at risk for adverse reactions due to her medication regimen and directed staff to monitor for side effects and administer medications as ordered. The facility's policy required staff to check and verify vital signs before administering medications when necessary. Despite these directives, staff administered midodrine outside of the prescribed parameters on several occasions, as evidenced by the MAR and staff interviews.
Failure to Label Insulin Flex Pens with Opened and Expiration Dates
Penalty
Summary
The facility failed to ensure that insulin flex pens used for a resident were properly labeled with the date they were opened and their expiration date. During an observation of the medication treatment cart, it was found that a resident's Lantus insulin flex pen was not labeled with either the opened date or the expiration date. Interviews with a licensed nurse and an administrative nurse confirmed that the nursing staff were responsible for labeling and dating insulin flex pens when opened. The facility's own policy, as well as professional guidelines, require that medications be labeled with the resident's name, medication name, prescribed dose, strength, and expiration date when applicable. The lack of labeling was directly observed and verified by staff.
Failure to Coordinate and Document Hospice Services in Care Plan
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice for a resident with a terminal prognosis and multiple diagnoses, including senile degeneration of the brain, dementia, atrial fibrillation, and basal cell carcinoma. The resident was admitted to hospice care and required staff assistance with activities of daily living due to severely impaired cognition and bilateral lower extremity contractures. The care plan for the resident did not include specific instructions regarding the hospice services being provided, such as the frequency and type of hospice support visits, supplies and medical equipment covered by hospice, medications provided, or hospice contact information. Record review and staff interview confirmed that the facility lacked a care plan that coordinated with the hospice plan of care. The facility's policy required collaboration and communication with hospice to ensure the resident's needs were met, but this was not reflected in the resident's care plan. The deficiency was identified through observation, record review, and staff verification, demonstrating a lack of coordination and documentation necessary for the provision of hospice services.
Failure to Protect Resident from Intimidation and Potential Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R1, from intimidation and potential abuse. R1, who had diagnoses of dementia, depression, and high blood pressure, was documented as having severely impaired cognition and required substantial assistance with activities of daily living. The resident exhibited behaviors such as frequent crying, wandering, and threatening actions, and was at risk for declines in functioning and communication. Despite these needs, an incident occurred where a licensed nurse, identified as LN G, was reported to have pulled R1 down into her chair forcefully, which was perceived as abusive by a witness. The incident was captured on camera footage, showing R1 standing up from her wheelchair and LN G reaching out to pull R1 back into the chair. Witness statements from staff members indicated that LN G expressed frustration with R1 and made derogatory comments about dementia patients. Although the facility's investigation, including a review by the sheriff's office, did not substantiate the abuse allegation, the actions of LN G were seen as inappropriate and indicative of a lack of understanding of dementia care. The facility's failure to protect R1 from potential abuse and intimidation was evident in the handling of the situation by LN G. The nurse's actions and comments towards R1, combined with the lack of immediate intervention to prevent such behavior, placed R1 at risk for impaired psychosocial well-being. The facility's protocols for abuse and neglect were not effectively implemented, as evidenced by the incident and the subsequent investigation findings.
Elopement Incident Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision to prevent cognitively impaired Resident (R) 1, who was identified as high risk for elopement, from eloping through a facility window. Despite being equipped with a Wander Guard bracelet, R1 managed to exit through a window without setting off the alarm. R1 had a history of exit-seeking behavior since admission, expressed a desire to leave the facility, and was frequently observed gazing out of a window towards his home. The facility's care plan for R1 included interventions to distract him from wandering and to identify patterns of his behavior, but these measures proved insufficient in preventing the elopement incident on 03/30/24. R1's medical history indicated diagnoses of dementia, requiring assistance with personal care and supervision for ambulation. The Cognitive Loss/Dementia Care Area Assessment highlighted R1's cognitive impairment and elopement risk, while the Wandering Risk Assessment confirmed R1 as a high-risk wanderer. Despite these assessments and care plans in place, R1 managed to elope through a window that lacked proper security measures, such as a missing screen. The incident not only exposed R1 to immediate jeopardy but also raised concerns about the facility's ability to provide adequate supervision for residents with high elopement risks. The series of events leading to R1's elopement highlighted gaps in the facility's supervision protocols and interventions for residents at risk. R1's behavior, history of exit-seeking, and expressed desire to leave the facility were clear indicators of the need for heightened vigilance. The facility's failure to prevent R1's elopement through a window that lacked proper security measures underscored the critical importance of tailored supervision and environmental safeguards for residents with cognitive impairments and elopement risks.
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Illustrative
What surveyors actually found near you
We read the 53 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
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Illustrative
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Nursing homes near Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastridge | 15.3 mi | ★★★★★ | 14 | 1 |
| Cambridge Place | 15.8 mi | ★★★★★ | 29 | 0 |
| Onaga Operator, Llc | 19.4 mi | ★★★★★ | 10 | 0 |
| Life Care Center Of Seneca | 19.9 mi | ★★★★★ | 0 | 0 |
| Crestview Nursing & Residential Living | 20.6 mi | ★★★★★ | 0 | 0 |
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