Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Kansas Soldiers Home during CMS and state inspections, most recent first.
The facility did not provide proper care for pressure ulcers and failed to prevent new ulcers from developing. Surveyors found that a resident did not receive consistent assessment, monitoring, or treatment for pressure ulcers, and that preventive measures were not adequately implemented for those at risk.
Surveyors observed that dietary staff failed to consistently follow proper hand hygiene and glove use during food preparation and serving. Staff were seen discarding soiled gloves into uncovered trash cans, donning new gloves without hand washing, and handling multiple food items and equipment with the same gloves, contrary to facility policy. These actions resulted in unsanitary food handling conditions.
The facility did not ensure that kitchen garbage and refuse were properly maintained and disposed of, as observed when trash cans inside lacked lids and outside bins were found with lids open. Staff were unable to account for the missing or open lids, which was not in accordance with the facility's waste disposal policy requiring sealed containers.
The facility did not consistently implement an infection prevention and control program, failing to use Enhanced Barrier Precautions for residents with catheters, wounds, or artificial openings. Staff were observed providing catheter care without required PPE or aseptic technique, and there was no signage or accessible PPE in resident areas. Administrative nurses were unaware of updated CMS requirements, and infection tracking was not performed in real time. The facility also lacked a water management program and policy to prevent Legionella.
The facility did not implement an effective antibiotic stewardship program, failing to track and trend antibiotic use for several residents who received antibiotics for urinary tract infections. Nursing staff confirmed that antibiotic use was not consistently documented or reviewed for appropriateness, and the infection control policy did not address these deficiencies.
The facility did not complete annual performance evaluations for five CNAs employed for over a year, as shown by employee file reviews and staff interviews. No signed evaluations were found for these CNAs, and the facility could not provide a policy on annual evaluations, despite an expectation for full compliance.
Staff failed to administer medications according to professional standards, with multiple residents receiving late medications and staff not verifying orders using the electronic MAR. Nursing staff acknowledged overdue medications and the absence of a liberalized medication pass policy, while administrative staff confirmed expectations for timely administration were not met.
A medication error rate of 52.94% was identified when a certified medication aide administered multiple scheduled medications to a resident significantly later than the prescribed time, based on incorrect training about what constitutes a late dose. The facility did not have a liberalized medication pass policy, and the nurse confirmed that medications were expected to be given on time.
A resident with major depressive disorder and intact cognition was prescribed a daily antidepressant without a documented informed consent form. Staff interviews confirmed the absence of the required consent, and the facility could not provide a policy on informed consent for psychotropic medications.
A resident with COPD and atrial fibrillation, who was cognitively intact but had impaired mobility, was required to wear a seatbelt on a motorized wheelchair that he could not independently release. Staff and documentation failed to assess or address the seatbelt as a restraint, and no care plan or physician order was in place. The resident reported he was told to wear the seatbelt without being given a choice, and staff confirmed no safety assessment or documentation existed for seatbelt use.
A resident with depression and anxiety was routinely administered antipsychotic and antidepressant medications without documented evidence of behaviors warranting antipsychotic use, unsuccessful nonpharmacological interventions, or a risk versus benefit analysis. Staff and pharmacy consultant interviews confirmed the lack of appropriate diagnosis and documentation, and the facility could not provide a policy on psychotropic medication use.
A resident with depression, anxiety, and pain continued to receive Celebrex despite a consultant pharmacist's recommendation to consider discontinuation due to elevated creatinine and low hemoglobin. The physician declined the recommendation without providing a rationale, and staff interviews revealed uncertainty about documentation requirements for pharmacy recommendations, contrary to facility policy.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that the facility did not consistently follow established protocols for pressure ulcer prevention and care, resulting in inadequate interventions for residents with existing ulcers and insufficient preventive actions for those at risk.
Failure to Maintain Sanitary Food Preparation and Handling Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically in the preparation and serving of food. During a kitchen tour, three barrel-type trash cans were found without lids, and staff were unable to locate one of the missing lids. Dietary staff were seen discarding soiled gloves into an uncovered trash can and then donning new gloves without washing their hands. Additionally, staff were observed handling multiple food items and kitchen equipment with the same pair of gloves, including touching plates, bread, and containers, without changing gloves or washing hands in between tasks. The Certified Dietary Manager confirmed that staff are expected to provide food in a safe and healthy environment and that annual food handling training is provided. The facility's hand washing policy requires frequent hand washing, especially after handling soiled equipment and during food preparation, to prevent cross-contamination. However, observations revealed that staff did not consistently follow these procedures, resulting in unsanitary food handling practices.
Improper Disposal and Maintenance of Kitchen Garbage and Refuse
Penalty
Summary
The facility failed to properly maintain and dispose of kitchen garbage and refuse, as observed during two separate inspections. During a kitchen tour, three barrel-type trash cans were found without lids, and staff were only able to locate lids for two of them. Additionally, an inspection of the outside garbage bins revealed that two out of eight bins had their lids open, despite calm weather conditions. The Certified Dietary Manager was unable to provide a reason for the open lids at the time of observation. According to the facility's waste disposal policy, all garbage is to be disposed of daily and placed in sealed containers outside the premises.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a consistent infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, wounds, and surgical artificial openings. Observations revealed that staff did not use required personal protective equipment (PPE) such as gowns during high-contact care, and there was no signage or accessible PPE in or around the rooms of affected residents. Staff members, including a CNA, were unaware of EBP requirements and did not follow aseptic technique when providing catheter care, such as cleaning the outlet tube with an alcohol wipe after emptying the drainage bag. Administrative nurses confirmed they were not aware of the updated CMS directive for EBP and acknowledged that infection control logs were not completed or reviewed in a timely manner to track and trend infections as they occurred. Additionally, the facility did not have a documented water management program to mitigate the risk of Legionella and other waterborne pathogens, nor did it have a policy addressing the prevention of Legionella. The infection control program documentation was incomplete, lacking evidence of surveillance systems to identify and track infections in real time. The facility's failure to implement these infection control measures and maintain proper documentation had the potential to contribute to the spread of infections among residents, particularly those with indwelling devices or wounds.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with protocols for antibiotic use and a system to monitor antibiotic use. Review of facility records showed that, out of a census of 51 residents and a sample of 15, seven residents received antibiotics during the review period. However, the infection control surveillance log did not document tracking or trending of antibiotic use for residents with recurrent urinary tract infections who received gentamycin bladder irrigations or for those who received amoxicillin for urinary tract infection. The log lacked documentation for these cases, and the administrative nurse confirmed that antibiotic use was not consistently tracked or trended, and that the July log was incomplete. Interviews with administrative nursing staff revealed that antibiotics were prescribed by physicians, but the facility did not conduct formal reviews or audits to determine the appropriateness or effectiveness of antibiotic use. The administrative nurse stated that documentation was typically completed at the end of each month and not tracked daily. Additionally, the facility's infection control policy did not address the identified areas of concern related to antibiotic stewardship and monitoring.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for over 12 months, as identified through interviews and review of employee files. The review of records showed that none of the five CNAs had a performance evaluation signed by management within the required 12-month period. During an interview, administrative staff confirmed the expectation for 100 percent compliance with annual evaluations, but the facility was unable to provide a policy regarding annual performance evaluations. The census at the time was 51 residents, and the lack of evaluations was observed for CNAs with varying lengths of employment, some dating back several years.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
The facility failed to ensure that medication administration services met professional standards of quality. Observations revealed that a Certified Medication Aide (CMA) prepared medications for residents without verifying orders using the electronic Medication Administration Record (MAR). Multiple residents' names were highlighted in pink on the computer screen, indicating overdue medications. When questioned, the CMA did not provide an explanation and walked away. A Licensed Nurse (LN) confirmed that 14 residents had overdue medications scheduled for 07:30 AM, and acknowledged that the facility did not have a liberalized medication pass policy. The LN stated that it was difficult to administer medications on time to independent residents and that staff did not have time to locate them for timely administration. Further observations showed that another CMA administered 07:30 AM scheduled medications to a resident at 09:52 AM, resulting in 18 oral and one inhaled medication being given late, with the resident declining a nasal spray. Interviews with administrative nursing staff confirmed that medications were expected to be administered on time and that the facility did not have a policy allowing for flexible medication pass times. The facility's policy required adherence to the right drug, dose, time, route, indication, and documentation, but staff training and practice did not align with these standards, as evidenced by the late administration and lack of MAR verification.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During the survey, 35 medication administration opportunities were observed, resulting in 22 errors and a calculated error rate of 52.94 percent. One resident's July Medication Administration Record/Treatment Administration Record showed 18 oral medications, two nasal sprays, and one inhaled medication scheduled for administration at 07:30 AM. Observation revealed that a Certified Medication Aide administered the 07:30 AM medications at 09:52 AM, outside the one-hour window before or after the scheduled time, resulting in 18 late oral medications and one late inhaled medication; the resident declined the nasal spray. The Certified Medication Aide reported being trained by another aide who instructed that medications were only considered late after 10:00 AM. The Administrative Nurse confirmed the scheduled time and stated there was no liberalized medication pass policy in place. Facility policy requires medications to be administered at the right time, among other standards.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain an informed consent form for a psychotropic medication prescribed to a resident diagnosed with major depressive disorder. The resident, who demonstrated intact cognition as evidenced by BIMS scores of 15 and 14 on recent assessments, was receiving bupropion HCl daily for depression. Documentation in the resident's care plan and assessment area noted the use of antidepressant medication and the need to monitor for adverse effects, but there was no evidence of a signed informed consent for the psychotropic medication in the resident's electronic medical record. Observations confirmed the resident's daily activities and use of assistive devices, while interviews with facility staff revealed that only two other residents had consent forms on file for psychotropic medications. The administrative nurse acknowledged the absence of an informed consent for this resident, and a consultant confirmed that all psychotropic medications should have consent forms, noting that the necessary form had been sent to the administrative nurse previously. The facility was unable to provide a policy on informed consent for psychotropic medications.
Failure to Assess and Document Use of Wheelchair Seatbelt as Physical Restraint
Penalty
Summary
Staff failed to ensure an environment free from physical restraints for a resident who used a motorized wheelchair with a seatbelt. The resident, who had diagnoses including COPD and atrial fibrillation and demonstrated intact cognition, was observed wearing a seatbelt that he could not independently release. Documentation in the electronic health record, care plan, and physician orders did not address the use of the seatbelt, nor was there evidence of an assessment of the resident's ability to release it. Staff interviews confirmed that the resident was required to wear the seatbelt, was unable to remove it on his own, and that no seatbelt safety assessment or care plan was in place for any resident. The resident reported he was told he had to wear the seatbelt and did not have a choice in the matter. Observations showed the seatbelt remained engaged for extended periods, and staff were responsible for applying and releasing it. Staff also indicated that not all residents required seatbelts and that it was policy for residents using electric wheelchairs to wear them, but there was no clear process for evaluating whether a seatbelt constituted a restraint. The facility's policy required a practitioner's order for a restraint, but no such order or documentation was present for the seatbelt. The lack of assessment, documentation, and resident choice led to the use of a physical restraint without proper justification or oversight.
Failure to Document Indication and Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication, specifically an antipsychotic, had an appropriate clinical indication or a documented physician rationale for its continued use. The resident had diagnoses of depression and anxiety, with cognitive impairment documented over time. Despite the use of antipsychotic and antidepressant medications, there was no evidence in the medical record of behaviors that would warrant antipsychotic use, nor was there documentation of unsuccessful nonpharmacological interventions or a risk versus benefit analysis for the continued use of the antipsychotic. The resident's care plan included general instructions for monitoring and consulting with the pharmacy and physician, but lacked specific documentation of attempts at gradual dose reduction or alternative therapies. Review of the medication regimen and pharmacy consultant notes did not identify a clear diagnosis or justification for the antipsychotic medication, and staff interviews confirmed uncertainty regarding the appropriateness of the diagnosis for the medication. The facility was unable to provide a policy on psychotropic medication use. These actions and omissions resulted in the resident being at risk for adverse effects associated with unnecessary psychotropic medication use.
Failure to Document Physician Rationale for Pharmacy Recommendation
Penalty
Summary
The facility failed to act upon a consultant pharmacist's recommendation during the monthly medication regimen review for a resident with diagnoses of depression, anxiety, and pain. The pharmacist identified elevated creatinine levels and low hemoglobin in the resident's laboratory results and recommended considering discontinuation of Celebrex due to potential renal or gastrointestinal involvement. The physician responded to the recommendation by declining to discontinue the medication but did not provide a rationale for this decision, as required by facility policy. Documentation in the resident's electronic health record and care plan confirmed ongoing administration of Celebrex despite the pharmacist's concerns. Interviews with facility staff revealed a lack of understanding regarding the requirement for physicians to document a rationale when not following pharmacy recommendations. The administrative nurse and pharmacy consultant both indicated that a rationale was only necessary for gradual dose reductions of psychotropic medications, not for other pharmacy recommendations. The facility's drug regimen review policy, however, required an appropriate response from physicians concerning previous drug regimen review recommendations or drug irregularities, which was not met in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Dodge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor Of The Plains | 1.3 mi | ★★★★★ | 12 | 0 |
| Trinity Manor | 1.6 mi | ★★★★★ | 0 | 0 |
| Sunporch Of Dodge City | 1.6 mi | ★★★★★ | 1 | 0 |
| Southwind At Spearville | 15.9 mi | ★★★★★ | 19 | 0 |
| The Shepherd's Center | 18.5 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.