Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Kansas Christian Home during CMS and state inspections, most recent first.
Unsanitary food storage and kitchen conditions were observed during a kitchen tour. Surveyors found debris and dried-on fluids in the freezer, refrigerator, prep table, and trash can, 13 discolored cutting boards with deep grooves, a box of buns stored on the floor of the walk-in freezer, and worn flooring in the dry supply room. Dietary Staff BB confirmed the areas needed cleaning or repair.
A facility failed to ensure ADL assistance was provided for multiple residents who needed help with personal hygiene. One resident with dementia and severe cognitive impairment had repeated long facial hairs on her chin despite a care plan for staff assistance. Several other residents with cognitive impairment or other diagnoses were observed with long, dirty fingernails or dried-on debris under the nails, while staff said nail care and shaving were typically done on shower days. An admin nurse stated staff were expected to trim and smooth fingernails as needed, and the facility did not provide an ADL policy when requested.
A resident with anxiety, insomnia, bipolar disorder, OCD, and severe cognitive impairment received multiple psychotropic medications, including antipsychotic, anti-anxiety, hypnotic, and antidepressant drugs. The EMR lacked evidence of informed consent that included the risks vs benefits and expected therapeutic benefit for these medications, and an Administrative Nurse confirmed the signed consent forms were missing.
Failure to Invite Resident to Care Plan Meetings: A resident with intact cognition, anxiety, depression, and max ADL assistance was not shown to have been invited to or included in care plan meetings. The EMR had no care conference documentation after one note, and staff interviews confirmed uncertainty about when the last meeting occurred and how invitations were handled, despite the care plan calling for resident participation.
A facility failed to obtain stop dates for PRN lorazepam orders for two residents receiving psychotropic meds. One resident had anxiety and severe cognitive impairment, and another had anxiety disorder, dementia, and hospice status with moderately impaired cognition and delusions. Both residents had lorazepam PRN orders without stop dates, and one resident received the medication multiple times over the month. An RN confirmed the missing stop dates, and the facility’s psychotropic medication guidance required a 14-day stop date for PRN psychotropics.
Failure to timely report alleged abuse: A resident with dementia, encephalopathy, and fluctuating cognition had an allegation that his wife slapped him, reported by a CNA who said she witnessed the event and completed a statement. Facility staff later said the allegation was investigated and not substantiated, but the DON/administrative nurse stated it was not reported to the SA because it was reported days later. The facility policy required allegations of abuse to be investigated and reported within required federal timeframes.
Failure to implement resident-specific fall interventions: A resident with bipolar disorder, severe cognitive impairment, and a documented high fall risk had repeated falls, including during a transfer when staff did not use the ordered gait belt and later when he attempted to transfer himself unassisted. The care plan called for a gait belt with one staff for all transfers and room signage to prompt call-light use, but staff were unsure of the resident’s fall interventions and the documented interventions were not appropriate for preventing further falls.
Failure to Monitor Ordered Fluid Restriction: A resident with DM, CKD, an indwelling catheter, and recurrent UTI had an active 1800 ml fluid restriction ordered with an NCS/2-gram sodium diet, fortified foods, and supplements. The EMR lacked fluid intake tracking, an LN believed the restriction had been discontinued even though it was still ordered, and staff confirmed the resident’s intake was not being recorded despite set fluid amounts being provided by dietary and nursing.
A pharmacy consultant failed to identify and report medication irregularities during monthly MRRs for two residents receiving PRN lorazepam. One resident had anxiety and severe cognitive impairment, and the other had anxiety disorder, dementia, and hospice care; both had PRN lorazepam orders without stop dates, but the consultant did not report the missing stop dates to the MD, DON, or facility leadership as required by policy.
A resident with dementia, a terminal prognosis, and significant assistance needs had hospice services in place, but the care plan did not include key hospice details such as visit frequency, medications, supplies, or medical equipment. Staff interviews showed the hospice nurse visited weekly and the hospice aide twice weekly, while one nurse relied on the physician order for the hospice contact number and was unclear about using the care plan for hospice service and supply information.
A CMA administered eye drops to a resident while wearing only one glove, holding the bottle with an ungloved hand and using the same tissue for both eyes. An LPN also removed gloves and reapplied new gloves during a heel dressing change without hand hygiene, then continued the wound care and dated the dressing afterward.
Failure to document vaccine offerings and declinations: one resident’s EMR lacked evidence that the pneumococcal vaccine was administered or properly declined after the RP wrote “wants all” on the declination form, and another resident’s EMR lacked documentation that the influenza vaccine was offered for the flu season. An Administrative Nurse could not locate the influenza form, and another Administrative Nurse stated she expected residents’ EMRs to show whether flu and pneumococcal vaccines were offered, given, or declined.
The facility failed to document COVID-19 vaccine offerings and informed declinations for two residents. One resident's EMR lacked evidence the vaccine had been offered since 2022, and another resident's EMR lacked evidence since 2021. An admin nurse could not locate recent forms showing the vaccine was offered, provided, or declined, and another admin nurse stated the EMR should contain this information.
A resident with significant medical conditions, including non-weight bearing status and an above-the-knee amputation, was injured when staff failed to follow the care plan for transfers. Instead of using a slide board as instructed, staff performed a stand and pivot transfer, resulting in fractures to the resident's right lower leg. The facility's policy for safe lifting and movement was not adhered to, leading to this deficiency.
The facility failed to maintain sanitary conditions in food storage and preparation areas, risking potential foodborne illness. Observations included unsealed bags of rice and flour, expired and undated food items, and improper storage of frozen foods. Kitchen equipment was found dirty, and a floor cleaning machine was stored near clean items. Dietary staff confirmed these issues, violating the facility's food storage policy.
The facility did not conduct annual performance reviews for two CNAs/CMAs, with one evaluation 22 months overdue and another 19 months overdue. Administrative Staff D confirmed the requirement for annual evaluations, but the facility lacked a policy to ensure completion, impacting care for all residents.
The facility failed to serve food at safe and palatable temperatures, as multiple residents reported receiving cold meals. Observations revealed that dietary staff did not consistently monitor or record food temperatures, with items like broccoli and cheesecake served at unsafe temperatures. The facility's electronic temperature monitoring system was unsatisfactory, leading to reliance on a paper system that also failed to ensure proper temperature maintenance.
A resident admitted with conditions such as chronic subdural hemorrhage and muscle weakness did not have a comprehensive person-centered care plan developed within the required timeframe. The care plan was delayed due to oversight by a previous MDS nurse, leading to potential uncommunicated needs and negative impacts on the resident's well-being.
A resident with a history of cerebral infarction, diverticulitis, and anemia experienced true weight loss, which was not addressed in their care plan. Despite physician orders for supplements and snacks, the care plan lacked documentation of these interventions. Facility staff confirmed the oversight, acknowledging the failure to update the care plan as required by policy.
A resident with a history of cerebral infarction and moderate cognitive impairment experienced significant weight loss, but the facility failed to obtain daily weights as ordered by the physician. Despite the order being in place since late March, daily weights were not documented until early June. This oversight in monitoring potentially affected the resident's physical well-being, as staff interviews revealed inconsistencies in documentation and understanding of the care plan.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as observed during an initial kitchen tour and confirmed by Dietary Staff BB. Surveyors noted food debris on the bottom shelf of the reach-in freezer, dried-on fluids on the bottom shelf of the two-doored reach-in refrigerator, and food debris on the bottom shelf of the preparation table where clean pots and pans were stored. They also observed 13 discolored cutting boards with deep grooves, a trash can by the dish washing sink with dried-on food and fluids on the lid, an unopened box of hot dog buns resting directly on the floor of the walk-in freezer, and a dry supply room floor that was worn down to the subflooring in several areas. The facility policy for Cleaning and Sanitizing stated that all new hires and current employees would be educated on proper methods for cleaning and sanitizing to prevent the potential for food borne bacteria.
Failure to Provide ADL Assistance With Facial Hair Removal and Nail Care
Penalty
Summary
The facility failed to ensure residents received assistance with activities of daily living, specifically facial hair removal and nail care, for multiple residents who required staff help with personal hygiene. Resident 21 had diagnoses of dementia and severe cognitive impairment, required maximal assistance with personal hygiene, and had a care plan directing staff to provide supervision/touching assistance for personal hygiene. During observations, she was seen on multiple occasions with several long white facial hairs on her chin, and staff stated that facial hair removal and nail care were typically completed during morning care for non-diabetic residents. Resident 45 had diagnoses of depression and anxiety, intact cognition, and required moderate assistance with personal hygiene. His care plan directed staff to provide maximal assistance with personal hygiene. He was observed with long fingernails on all fingers on multiple days, and he reported that he could not cut them himself and that staff should cut them on bath day. Nail clippers were observed on the TV stand and not within his reach. Staff stated that residents' fingernails would be cut on shower days, and an administrative nurse stated staff were expected to shave residents every shower day or as needed, with nurses cutting diabetic residents' fingernails. Resident 6, Resident 16, and Resident 18 each had diagnoses and MDS findings showing severe cognitive impairment and required substantial to maximal or total assistance with personal hygiene. Their care plans directed staff to provide assistance with ADLs or personal hygiene, and their EMRs showed ongoing need for moderate to dependent assistance. During observations, Resident 6 had dark brown dried-on substance under her fingernails, while Resident 16 and Resident 18 had long, dirty fingernails on repeated observations. Staff again stated that fingernail care was to be completed on shower days, and an administrative nurse stated the expectation was for staff to trim and smooth residents' fingernails on shower days and as needed. The facility did not provide a policy for ADLs when requested.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained for R4’s psychotropic medications, including antipsychotic, anti-anxiety, hypnotic, and antidepressant drugs. R4’s EMR documented diagnoses of anxiety, insomnia, bipolar disorder, and OCD, and the MDS assessments documented severe cognitive impairment with BIMS scores of six and seven. During the assessment period, R4 received psychotropic medications including clonazepam, duloxetine, Seroquel, sertraline, zolpidem, Ativan, and lorazepam, and the MAR showed staff administered the medications as ordered. R4’s EMR lacked evidence of psychotropic medication consent that included the risks versus benefits and the expected therapeutic benefit of the medications. The Psychotropic Drugs CAA noted that several psychotropic medications were reviewed monthly by the pharmacy consultant and physician to maintain therapeutic uses, and the care plan instructed staff to monitor and report adverse side effects from the psychotropic medications. On interview, the Administrative Nurse stated that R4’s EMR lacked signed consent forms for the psychotropic medications. The facility policy stated psychotropic medications would only be initiated after informed consent was completed and signed, with a new consent completed with each dosage change.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to ensure Resident 38 was given the opportunity to participate in the development and implementation of her person-centered plan of care when staff did not invite her, or her responsible party, to care plan meetings. Resident 38’s EMR documented diagnoses of anxiety and depression, and her Annual MDS showed a BIMS score of 15, indicating intact cognition. The record also showed she required maximal assistance with ADLs, had no behaviors, and participated in restorative programs with some improvement noted in the look-back period. Resident 38’s care plan documented that staff would encourage her to make her own decisions and provide support as needed. However, the EMR contained only one care conference note, dated 09/10/25, and no evidence of a care plan conference after that date. During interviews, Resident 38 stated she was unsure when she last attended or was invited to a care plan meeting. SSD X reported that an email would be sent to the resident’s DPOA and that the resident was given an invitation by hand, while Administrative Nurse E stated the last care conference note she could locate was from 09/10/25 and that care plan meetings were expected every three months. The facility policy stated the resident, family, and/or legal representative are encouraged to participate in care plan development and revisions, and every effort will be made to schedule meetings at the best time for the resident and family.
Missing Stop Dates for PRN Lorazepam Orders
Penalty
Summary
The facility failed to obtain stop dates for PRN lorazepam orders for two residents receiving psychotropic medications. R4 had diagnoses of anxiety and severe cognitive impairment, with care plan instructions to monitor and report adverse side effects from psychotropic medications. R4’s physician ordered lorazepam 1 mg every 3 hours PRN for anxiety, not to exceed six doses per day, but the order did not include a stop date. On 05/13/26, Administrative Nurse D confirmed the PRN lorazepam order lacked a stop date. R3 had multiple diagnoses including anxiety disorder, dementia, senile degeneration of the brain, and hospice status, and the MDS documented moderately impaired cognition and delusions. R3’s care plan addressed depression related to dementia and directed staff to administer medications as ordered and monitor for side effects and effectiveness. The physician ordered lorazepam 0.5 mg every six hours PRN for anxiety and restlessness, and another lorazepam oral concentrate order for agitation/restlessness, both without stop dates. The EMAR showed R3 received PRN lorazepam 15 times in April and five times in May, and Administrative Nurse D stated on 05/14/26 that the PRN lorazepam should have had a stop date and the pharmacist had not caught it during monthly reviews. The facility’s psychotropic medication use guidance stated residents admitted with a PRN psychotropic should have a 14-day stop date and a practitioner review before continued use.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required time frame for a resident with dementia, encephalopathy, hearing loss, and fluctuating cognition documented on MDS assessments. The resident’s records showed varying cognitive status, including a BIMS score of 15 on one annual MDS and a BIMS score of 6 on a quarterly MDS, with no behaviors documented. His care plan noted that his wife was allowed to sleep in his room overnight for support, and later facility notes documented restricted visitation hours and rules for the wife, including that she was not to stay overnight except under limited circumstances and was to leave during care. A CNA reported that the resident’s wife slapped him sometime in October 2025 and stated she had reported the incident to the charge nurse and completed a witness statement, with another CNA reportedly present and also writing a statement. The SSD later reported that the CNA, who was her family member, told her about the alleged slap, and the SSD said she then reported the allegation to an administrative nurse because of a conflict of interest. The administrative nurse stated the allegation was not reported to the State Agency because it was reported days later and was not substantiated after investigation. An administrative staff member stated he expected any allegation of abuse to be reported to the State Agency. The facility policy required all possible incidents of abuse, neglect, mistreatment, or misappropriation to be identified, investigated, and reported within federal timeframes.
Failure to implement resident-specific fall interventions
Penalty
Summary
The facility failed to identify and implement resident-centered fall interventions for a resident with bipolar disorder and severe cognitive impairment who was determined to be at high risk for falls. The resident’s EMR and MDS documented a BIMS score of 6 on one assessment and 7 on a later assessment, along with a history of multiple falls, including one non-injury fall and one injury fall since the prior assessment. The Falls CAA also documented that the resident was at high risk for falls with two falls since the prior assessment. The care plan, revised 03/02/26, directed staff to use a gait belt with one staff for all transfers and to place brightly colored signs in the room reminding the resident to use the call light for transfers. Despite these documented interventions, the resident fell on 03/02/26 while being transferred from a shower chair to a wheelchair when staff attempted the transfer without using a gait belt. The resident fell again on 04/11/26 when he attempted to transfer himself from a recliner to a wheelchair unassisted. Staff interviews indicated uncertainty about the resident’s fall interventions, and one nurse stated that new interventions were usually implemented after a fall, while an administrative nurse confirmed the fall interventions were not appropriate for preventing further falls. The facility policy stated that staff shall identify interventions related to the resident’s specific risks to try to prevent further falls.
Failure to Monitor Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor Resident 6’s physician-ordered fluid restriction. Resident 6 had multiple diagnoses including DM, major depressive disorder, chronic pain syndrome, nutritional deficiency, generalized anxiety disorder, chronic kidney disease, a history of urinary calculi, and UTI. The resident’s Significant Change MDS documented moderately impaired cognition, continuous inattention, disorganized thinking, hallucinations, and delusions. The resident required assistance with eating and transfers, was dependent for toileting hygiene, had an indwelling catheter, received scheduled pain medication, complained of coughing or choking during meals or when swallowing medication, and was on a therapeutic diet. The resident’s care records documented an NCS diet with an 1800 ml fluid restriction, and the physician order also specified a 2-gram sodium diet with 1800 ml fluid restriction, fortified foods, 120 ml of 2Cal three times daily, and a house supplement three times daily. The EMR lacked evidence of tracking the resident’s fluid intake. During observation and interview, the resident was seen with fluids in the dining room, dietary staff reported providing set amounts of fluids with meals, and an LN stated she thought the fluid restriction had been discontinued even though the order remained active. The LN also confirmed the fluid intake had not been recorded, and an administrative nurse stated the fluid restriction had not been transferred into the new EMR when the software changed and that the resident’s fluid intakes should have been monitored and recorded.
Pharmacy Consultant Failed to Report Missing Stop Dates for PRN Lorazepam
Penalty
Summary
The facility failed to ensure the consultant pharmacist completed monthly medication regimen reviews and reported medication irregularities to the resident’s physicians and facility leadership. The pharmacy consultant reviewed the medication records for two residents receiving PRN lorazepam, but did not identify or report that the PRN orders lacked stop dates, as required by the facility’s policy for medication regimen review and communication of medication irregularities. One resident had diagnoses of anxiety and severe cognitive impairment, with care plan instructions to monitor and report adverse effects from psychotropic medications. The resident’s EMR showed a physician order for lorazepam 1 mg every 3 hours PRN for anxiety, not to exceed six doses per day, ordered 03/02/26, and the order lacked a stop date. The consultant pharmacist reviewed the resident’s medications on multiple monthly dates, but the administrative nurse confirmed on 05/13/26 that the PRN lorazepam order lacked a stop date and that the consultant pharmacist failed to identify it. The second resident had multiple diagnoses including anxiety disorder, dementia, senile degeneration of the brain, and hospice care, and required substantial assistance with several activities of daily living. The resident’s physician orders included lorazepam 0.5 mg by mouth every six hours PRN for anxiety and restlessness and a second lorazepam order for agitation/restlessness; both orders lacked stop dates. The consultant pharmacist’s medication reviews documented other recommendations, but did not include a request for a stop date for the PRN lorazepam. The administrative nurse stated the PRN lorazepam should have had a stop date and verified the pharmacist had not identified the issue during monthly reviews.
Hospice Collaboration and Care Plan Information Missing
Penalty
Summary
The facility failed to ensure collaboration between the facility and hospice for Resident 3, including hospice visit frequency, medications, medical equipment, and the resident representative’s preference. Resident 3’s record showed diagnoses of diabetes mellitus, hearing loss, need for assistance with personal care, anxiety disorder, dementia, senile degeneration of the brain, and a left femur fracture. The significant change MDS documented moderately impaired cognition, delusions, and substantial to maximal assistance needs for toileting hygiene, bed mobility, transfers, and related care, with partial to moderate assistance needed for upper body dressing and personal hygiene. The MDS also documented scheduled pain medications, PRN pain medication, and non-medication pain interventions. Resident 3’s care plan identified a terminal prognosis related to senile degeneration of the brain and listed the hospice provider’s name, address, and phone number, with direction to consult the physician and social services for hospice care in the facility. However, the care plan did not include the frequency of licensed nurses, clergy, nurse aides, social services, medications, supplies, or medical equipment provided by the hospice provider. The physician order directed admission to hospice for the terminal diagnosis. During observation and interviews, Resident 3 was eating in her room, reported being hard of hearing, and asked questions be written down. She stated she had no complaints but wanted her family to visit more often because she was lonely. Staff interviews indicated the hospice nurse visited once weekly and the hospice aide twice weekly, while the hospice provider supplied briefs, wipes, underpads, and creams; one nurse stated she would look to the physician orders for the hospice contact number and was not clear on using the care plan for hospice services and supplies. Administrative staff stated the prior care plan had contained hospice service, medication, and supply information, but that information had not been transferred after a software change.
Hand hygiene not performed during eye drop administration and dressing change
Penalty
Summary
The facility failed to ensure adequate hand hygiene during eye medication administration for one resident. On 05/12/26 at 04:03 PM, CMA T applied only one glove to her left hand without performing hand hygiene, then administered one drop of timolol ophthalmic eye drops into each eye for R47. She held the eye drop bottle with her ungloved right hand, used her left hand to hold the resident’s eyelid open, and used the same tissue to wipe each eye after the medication was given. During interview, CMA T stated she did not realize she had only worn one glove and thought she used a different tissue. The facility also failed to ensure hand hygiene during a dressing change for R45. On 05/13/26 at 07:32 AM, LN H removed the dressing from the resident’s left heel with her right hand, cleansed the open area, removed the resident’s right sock and washed the right heel, then removed her gloves and applied new gloves without performing hand hygiene. She applied Skin-prep to the skin around the left heel wound and to the right heel, removed her gloves again without hand hygiene, opened a hydrogel dressing, reapplied gloves, and applied the dressing to the left heel with a foam adhesive dressing over it. She later removed her gloves, performed hand hygiene, and dated the dressing. LN H stated she should have performed hand hygiene when she removed her gloves and before applying new gloves during the dressing change.
Failure to Document Vaccine Offerings and Declinations
Penalty
Summary
The facility failed to offer and provide, or obtain an informed declination for, the pneumococcal vaccine for one resident. The resident’s EMR did not document that the pneumococcal vaccine was administered after the responsible party wrote “wants all” on the Vaccine(s) Declination form that listed COVID-19 vaccine, influenza vaccine, pneumococcal vaccine, and shingles vaccine. None of the vaccines on that form had a check mark in the declination column. The facility also failed to offer and provide, or obtain an informed declination for, the influenza vaccine for another resident. That resident’s EMR lacked documentation that the influenza vaccine was offered for the 2025 through 2026 flu season. On interview, the Administrative Nurse produced the requested influenza/pneumococcal vaccine forms and stated she could not locate an influenza form for that resident for the 2025-2026 influenza season. Another Administrative Nurse stated she expected all residents to have the influenza and pneumococcal vaccines offered and expected the EMR to contain information showing whether the vaccines were offered, administered, or declined. The facility policy stated that all residents, staff, and volunteers would be offered the influenza vaccine annually unless contraindicated or refused after appropriate education, and that all admissions throughout the year would be offered the pneumovax injection as desired by the resident and approved by the primary care physician after inquiry into immunization status.
Failure to Document COVID-19 Vaccine Offerings and Declinations
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document vaccination status for two residents. Resident 6's EMR did not contain documentation that a COVID-19 vaccine had been offered since 2022, and Resident 21's EMR did not contain documentation that a COVID-19 vaccine had been offered since 2021. During interview, an Administrative Nurse produced the requested COVID-19 vaccine forms and stated she could not locate a recent record showing that the vaccine had been offered and provided or that an informed declination had been obtained for either resident. Another Administrative Nurse stated she expected all residents to have the COVID-19 vaccine offered and expected the EMR to contain documentation if the vaccine was offered, administered, or declined. The facility did not provide a COVID-19 vaccine policy.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to protect a dependent resident from harm when staff did not follow the resident's care plan, which instructed the use of a slide board for transfers. On the day of the incident, a Licensed Nurse (LN) and a Certified Medication Aide (CMA) assisted the resident, who was in a wheelchair, to use the restroom. Despite the care plan's instructions, the staff performed a stand and pivot transfer instead of using the slide board, resulting in the resident sustaining fractures in her right lower leg. The resident had a history of significant medical conditions, including diabetes mellitus, osteoporosis, and a recent surgery on her right ankle due to a fracture. She was non-weight bearing on her right extremity and had an above-the-knee amputation on her left extremity. The care plan specified that the resident required total assistance for transfers and toileting, with the use of a mechanical lift initially, later revised to include a slide board for transfers. During the transfer, the staff heard a popping sound, and the resident complained of pain. An X-ray later confirmed that the resident had sustained a closed, comminuted, non-displaced tibial fracture and a distal fibular fracture. The facility's investigation revealed that the staff did not adhere to the care plan, which led to the resident's injury. The facility's policy for safe lifting and movement of residents was not followed, resulting in the deficiency.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and serving areas, which could lead to potential foodborne illness among residents. Observations revealed several issues, including unsealed bags of rice and flour in the dry goods pantry, an opened container of teriyaki sauce past its expiration date, and a gallon of Worcestershire sauce without an opened or expiration date. Additionally, frozen food was improperly stored directly on the floor of the walk-in freezer. Dietary staff confirmed that these items should have been placed on shelves. Further inspection during an environmental tour uncovered more concerns, such as an unidentified piece of meat in the refrigerator dated several weeks prior, and various expired food items, including thousand island dressing and salsa. The refrigerator also contained undated, wilted, and discolored lettuce. The kitchen equipment was found to be in poor condition, with a dirty oven, a grimy can opener, and a scratched fry pan. A floor cleaning machine was improperly stored near clean serving pans and storage containers. Dietary staff acknowledged these issues, which were in violation of the facility's food receiving and storage policy.
Failure to Conduct Annual Performance Reviews for CNAs/CMAs
Penalty
Summary
The facility failed to conduct annual performance reviews for two out of five Certified Nurse Aide/Medication Aides (CNA/CMA) reviewed, which is necessary to ensure residents receive adequate care. Specifically, the employment records showed that one CNA/CMA, hired in 1995, had their last performance evaluation 22 months past due, and another, hired in 2018, had their last evaluation 19 months past due. Administrative Staff D confirmed that CNAs/CMAs employed for more than a year should have annual evaluations, but the facility lacked a policy to ensure these evaluations were completed. This deficiency was identified through observation, interviews, and record reviews, affecting the care provided to all residents in the facility.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe and palatable temperatures, as required by their policy. Multiple residents reported receiving cold meals, with one resident specifically mentioning that meals served in their room were usually cold. Observations revealed that dietary staff did not consistently monitor or record food temperatures before serving. For instance, broccoli was served at 132 degrees Fahrenheit without prior temperature checks, and cheesecake was left unrefrigerated, reaching temperatures above 50 degrees Fahrenheit, which is above the safe limit of 42 degrees Fahrenheit. Further observations showed that food items like cut carrots and ground chicken were served at 100 degrees Fahrenheit, below the required 135 degrees Fahrenheit. The facility's electronic temperature monitoring system was reportedly unsatisfactory, leading staff to use a paper recording system, which also failed to ensure proper temperature maintenance. A test tray confirmed that scrambled eggs and hash browns were served at 100 degrees Fahrenheit, which was not hot enough, as confirmed by both dietary staff and surveyors. The facility's policy required potentially hazardous foods to be maintained at specific temperatures, which was not adhered to, resulting in the deficiency.
Failure to Timely Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R35, within the required timeframe. R35 was admitted with diagnoses including nontraumatic chronic subdural hemorrhage, muscle weakness, and repeated falls. The resident's Admission Minimum Data Set (MDS) indicated intact cognition, minimal depression, and a need for limited assistance with activities of daily living (ADLs). However, the comprehensive care plan was not completed within 21 days of admission, as required by the facility's policy. The care plan was only completed in November 2023, several months after the resident's admission, due to oversight by a previous MDS nurse who was no longer employed at the facility. Observations and interviews revealed that R35 was occasionally incontinent of bladder and required assistance with ambulation and toileting. Despite these needs, the care plan documentation was lacking, with no baseline care plan found in the Electronic Health Record (EHR). Staff interviews confirmed that the care plan was essential for understanding the care required by residents. The delay in developing a comprehensive care plan had the potential to lead to uncommunicated needs, which could negatively impact the resident's physical, mental, and psychosocial well-being.
Failure to Revise Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R1, regarding weekly weights and interventions to prevent further weight loss. R1 had a history of cerebral infarction, diverticulitis, and anemia, and was noted to have a stable weight according to the Nutritional Care Area Assessment (CAA) dated 12/14/23. However, by 07/02/24, it was identified that R1 had experienced a true weight loss, which was not due to fluid shifts. Despite this, the care plan dated 07/02/24 did not include interventions for weight loss, such as monitoring weekly weights or documenting the consumption of supplements and snacks ordered by the physician. Interviews with facility staff, including Administrative Nurse E and Dietary Staff BB, confirmed that the weight loss and necessary interventions were not included in R1's care plan. The facility's policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change, but this was not adhered to in R1's case. The lack of documentation and revision of the care plan for R1's weight loss was acknowledged by the staff, indicating a failure to communicate and address the resident's changing needs effectively.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to obtain daily weights for a cognitively impaired resident, identified as R1, who had an order for daily weights due to a significant weight loss. The resident had a history of cerebral infarction, diverticulitis, and anemia, and was noted to have moderately impaired cognition. Despite the physician's order for daily weights starting on 03/28/24, the facility did not document any daily weights until 06/07/24, which was a significant delay in monitoring the resident's weight. The resident experienced a notable weight loss, with records indicating a decrease of 16 pounds since 03/13/24, and further weight loss was documented in subsequent months. The resident's weight fluctuated significantly, with a documented weight of 161.2 lbs on 04/07/24, dropping to 138.0 lbs by 07/01/24. The facility's failure to adhere to the physician's order for daily weights potentially compromised the resident's physical well-being, as the weight loss was not adequately monitored or addressed in a timely manner. Interviews with facility staff revealed inconsistencies in the documentation and understanding of the resident's care plan. Licensed Nurse H and Administrative Nurse E acknowledged the oversight in daily weight documentation and the lack of a clear physician order for weekly weights. Additionally, the facility did not provide a policy regarding weight loss and adherence to physician orders, further highlighting the deficiency in the resident's care management.
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 263 citations issued within 25 miles in the last 12 months — including the 8 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
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 Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newton Presbyterian Manor | 0.7 mi | ★★★★★ | 11 | 0 |
| Paramount Community Living And Rehab Inc | 1.3 mi | ★★★★★ | 22 | 0 |
| Bethel Health Care Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Schowalter Villa | 8.3 mi | ★★★★★ | 0 | 0 |
| Halstead Health And Rehabilitation Center | 9.8 mi | ★★★★★ | 17 | 1 |
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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 July 2026) and official state health department websites.