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 Lansing Care And Rehab during CMS and state inspections, most recent first.
A cognitively impaired, wheelchair-dependent resident with severe dementia, impaired balance, and a history of falls required extensive staff assistance and two-person participation for bed mobility and transfers per the care plan. During an attempted transfer to bed while the resident was resisting, two CNAs repositioned the wheelchair, causing the resident’s angled left leg to strike the bed frame, after which the resident screamed that staff had broken her knee; one CNA then performed a hug transfer without the other’s help. The event was reported to a nurse, who initially noted no visible injury and believed the resident’s pain was at baseline, but bruising and significant pain on palpation were identified later, and imaging subsequently revealed an oblique proximal tibia and fibula fracture with soft tissue swelling that orthopedics characterized as acute. The facility’s accident policy emphasized maintaining an environment free from accident hazards and providing supervision and assistance based on individual risk factors.
A resident's CPAP mask was found unbagged and resting directly on a bedside table, contrary to facility protocols requiring respiratory equipment to be stored in dated bags when not in use. Staff interviews confirmed inconsistent adherence to this practice. Additionally, the facility lacked a comprehensive, facility-specific water management program to address Legionella and other waterborne pathogens, with only general documentation and a single test on record, and no evidence of ongoing risk assessment or monitoring.
Staff did not consistently lock medication and treatment carts containing treatment supplies, PRN creams, and insulin pens when the carts were not within the nurses' line of sight. Facility policy and staff interviews confirmed that carts should be locked when unattended to ensure safe and secure storage of drugs and biologicals.
Two residents experienced a lack of dignity and respect during care interactions. One resident, dependent on staff for all ADLs and cognitively intact, was spoken to disrespectfully by a CNA in her room. Another resident with severe cognitive impairment and physical limitations was fed by staff standing over him in the dining area, with his bare abdomen exposed to others. Staff interviews and facility policy confirmed these actions did not meet expected standards for resident dignity and respectful care.
A resident with severe cognitive impairment and total dependence on staff for care was subjected to verbal and emotional abuse when a CNA forcibly took away her comfort item and used derogatory language. This action violated the resident's care plan and the facility's abuse prevention policy, which require staff to treat all residents with respect and dignity.
A resident with dementia and severely impaired cognition was administered antipsychotic medications without appropriate physician documentation, including rationale, evidence of unsuccessful nonpharmacological interventions, or risk-benefit assessment. The facility's records included an unsigned consent form and lacked the required supporting documentation, despite policy requirements for such oversight.
A resident with multiple chronic conditions was admitted to hospice, but the facility did not complete the required Significant Change MDS or Care Area Assessment within the mandated timeframe. The resident's EMR also lacked a hospice admission order, and staff interviews revealed delays and unclear responsibility for MDS completion.
A resident with severe cognitive impairment, multiple medical diagnoses, and a history of falls did not have fall prevention interventions implemented as directed by the care plan. Observations revealed the call light was out of reach and the fall mat was not placed by the bed as required, despite staff and facility policy stating these measures should be in place.
A consultant pharmacist did not identify or report the absence of an Abnormal Involuntary Movement Scale (AIMS) test for a resident prescribed Reglan, despite the resident's medical history and ongoing medication regimen. Monthly medication reviews lacked documentation or recommendations for the required AIMS test, and nursing staff confirmed the assessment was not completed or available when requested.
A resident receiving Reglan for nausea, with a history of CHF, diabetes, and GERD, was not monitored for adverse effects using the AIMS test or any alternative method. Staff indicated that the facility's system did not trigger AIMS testing for this medication, and no policy for monitoring medication side effects was available upon request.
A resident with multiple chronic conditions was admitted to hospice, but the facility did not document the required physician order for hospice admission, failed to complete the Significant Change MDS and CAA within required timeframes, and omitted details about hospice-provided medications and equipment from the care plan. Staff interviews confirmed that this information should have been included per facility policy.
Failure to Provide Safe, Assisted Transfer Resulting in Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during a transfer for a cognitively impaired resident with severe dementia, generalized muscle weakness, impaired balance, history of falls, and dependence on staff for transfers and mobility. The resident’s MDS and care plans documented severe cognitive impairment (BIMS score of 4), dependence on staff for wheelchair mobility and transfers, and the need for substantial to maximal assistance with bed mobility, transfers, and ADLs. The care plan further specified that two staff were to participate in repositioning and turning the resident in bed, and that staff were to observe for and report redness, open areas, scratches, cuts, and bruises to the nurse. On the date of the incident, two CNAs attempted to assist the resident into bed while the resident was resisting and hitting staff. One CNA reported that, due to the wheelchair’s “weird” position, the assisting CNA swung the wheelchair toward the bed frame to turn it while the resident’s left leg was positioned behind the right leg at an angle. During this maneuver, the resident’s left knee hit the bed frame, and the resident immediately screamed and yelled that staff had broken her knee, using expletives. The witness CNA stated that the bed frame height aligned with the area of the resident’s later-observed bruise and that the resident’s leg position at the time of impact was as she demonstrated, with the left leg angled behind the right. The witness CNA further reported that, after repositioning the wheelchair, the assisting CNA decided to perform a “hug” transfer of the resident into bed without the witness CNA’s help, and the resident again cried out that staff had broken her knee. The CNAs reported to the nurse that the resident had bumped her leg on the bed frame and cried out in pain. Following the incident, the nurse who was informed the next morning assessed the resident and did not initially observe redness or bruising, and believed the resident’s pain was at baseline, noting the resident had a history of leg pain and frequent refusal of pain medication. Two days after the incident, a CNA reported bruising below the resident’s left knee, and a nurse documented facial grimacing and yelling upon palpation of the lower leg. An x-ray obtained at that time showed an oblique fracture of the proximal tibia and proximal fibula with soft tissue swelling and age-indeterminate fractures. The orthopedic clinic later documented that, although the exact timing and mechanism of the fracture were unclear, there were acute findings on the x-rays, including well-defined fracture lines and absence of healing, and the fracture would be treated as acute. The facility’s own accident policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities, using a systems approach that considers environmental hazards and individual resident risk factors.
Deficiencies in Infection Control: Improper CPAP Mask Storage and Inadequate Water Management Program
Penalty
Summary
The facility failed to ensure that a resident's continuous positive airway pressure (CPAP) mask was stored in a sanitary manner. During observation, the resident's unbagged CPAP mask was found resting directly on the bedside table, with no storage bag visible. The resident confirmed that the mask was usually not stored in a bag and that she did not have one for her CPAP mask. Interviews with staff revealed that the facility's practice was to store respiratory masks in dated bags when not in use, with the night shift responsible for ensuring bags were available and the day shift responsible for placing the mask in the bag. However, this protocol was not followed for the resident in question. Additionally, the facility failed to develop, implement, and maintain a comprehensive water management program to reduce the risk of Legionella and other waterborne pathogens. While documentation of Legionella testing and general monitoring instructions were available, they were not specific to the facility and lacked evidence of a risk assessment or ongoing monitoring to identify potential sources of Legionella growth. The maintenance staff was only aware of a single test conducted and did not have a detailed water management plan or diagram, indicating a lack of a systematic approach to water safety as required by facility policy.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
Staff failed to ensure that medication carts and treatment carts containing residents' treatment supplies, PRN creams, and insulin pens were always locked when not within the nurses' line of sight. On one occasion, a treatment cart was observed unlocked in a hallway, and an administrative nurse subsequently locked it. Interviews with nursing staff confirmed that facility policy requires medication and treatment carts to be locked if staff are not able to see them. The facility's policy, revised in October 2024, states that all drugs and biologicals must be stored in a safe, secure, and orderly manner.
Failure to Maintain Resident Dignity and Respect During Care Interactions
Penalty
Summary
The facility failed to provide a dignified care environment for two residents, resulting in deficiencies related to respect and dignity. One resident with quadriplegia, diabetes, anxiety disorder, and major depressive disorder, who was cognitively intact and dependent on staff for all activities of daily living, experienced an incident where a Certified Nurse's Aide (CNA) entered her room and responded to her inquiry with, "it's none of your business." The resident alleged the CNA used abusive language, which was partially corroborated by the CNA's admission to making a disrespectful comment. The care plan for this resident required at least two staff members to be present during interactions due to a history of allegations, but the report does not specify if this protocol was followed during the incident. Another resident with a history of stroke, diabetes, aphasia, and severe cognitive impairment, who was dependent on staff for all activities of daily living except eating, was observed being assisted with meals in a manner that did not maintain his dignity. Staff were seen standing over the resident while feeding him at the dining table, and his bare abdomen and right side were exposed to peers. Facility staff interviews confirmed that the expected practice was to sit beside residents while assisting with eating and to ensure residents' skin was covered in the dining area, but these standards were not upheld during the observed incidents. Facility policies on resident rights and respect and dignity, as well as staff interviews, emphasized the importance of treating residents with respect, maintaining their dignity, and following specific protocols for care and communication. However, the observed actions and interactions with the two residents did not align with these policies, resulting in a failure to honor the residents' rights to a dignified existence and respectful treatment.
Staff-to-Resident Verbal and Emotional Abuse Incident
Penalty
Summary
A staff-to-resident verbal and emotional abuse incident occurred involving a resident with severe cognitive impairment, dementia, muscle weakness, repeated falls, and dependence on staff for all activities of daily living. The resident, who used a wheelchair and relied on a stuffed bear as a coping mechanism, was subjected to abusive language by a Certified Nurse's Aide (CNA). The CNA forcibly took the resident's bear away against her wishes and called her a derogatory name. This incident was witnessed by another CNA, who reported the event. The resident's care plan required staff to provide structured routines, positive feedback, and activities compatible with her abilities, emphasizing respect and dignity. Despite these directives and the facility's policy prohibiting all forms of abuse, the staff member failed to uphold these standards, resulting in verbal and emotional abuse. The facility's policy defined mental abuse to include verbal conduct causing humiliation or agitation, which was directly violated in this incident.
Lack of Physician Documentation for Antipsychotic Use in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia and severely impaired cognition received antipsychotic medications only with appropriate physician documentation and rationale. The resident, who also had diagnoses of repeated falls, muscle weakness, and Parkinson's disease, was prescribed Haloperidol for hallucinations and Seroquel for anxiousness. The medical record and care plan indicated ongoing use of these medications, with monthly pharmacist reviews and physician oversight of recommendations. However, the facility was unable to provide documentation from the physician that included a clear rationale for the continued use of antipsychotic medications, evidence of multiple unsuccessful attempts at nonpharmacological interventions, or an assessment of the risks versus benefits for this resident. Additionally, the consent form for psychoactive medication therapy was unsigned and lacked the required physician documentation. Interviews confirmed that the facility used preprinted consent forms and that the resident was on hospice services, with the family requesting continuation of the antipsychotic medication. The facility's policy required that psychotropic drugs be used only when necessary for specific conditions and not for staff convenience or discipline, and that residents or their representatives have the right to refuse such treatment. Despite these requirements, the necessary physician documentation supporting the use of antipsychotic medication for this resident was not present.
Failure to Complete Significant Change MDS and CAA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment and the associated Care Area Assessment (CAA) for a resident who was admitted to hospice services. The resident, who had diagnoses of congestive heart failure, diabetes mellitus, and gastroesophageal reflux, was admitted to hospice, but the required Significant Change MDS was not completed within the mandated timeframe. Additionally, the CAA was not completed within 14 days after the initiation of the Significant Change MDS. The resident's electronic medical record did not contain an order for hospice admission, although an order was present on the hospice provider's certification form. Interviews with facility staff revealed that the nurse responsible for completing the MDS was behind due to providing direct care to residents. Another staff member indicated that both administrative and corporate staff were responsible for ensuring timely MDS completion as required by CMS. The facility was unable to provide a policy regarding the required timing for MDS completion when requested by surveyors.
Failure to Implement Fall Prevention Interventions as Directed by Care Plan
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with multiple medical conditions, including hypertension, diabetes, a history of stroke, pelvic fracture, dysphagia, aphasia, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living except eating, was nonverbal or rarely understood, and used a staff-propelled Broda chair for mobility. The care plan specified that the resident's bed should be kept in the lowest position, a fall mat should be placed next to the bed, and the call light should be within reach. However, during observations, the call light was found out of the resident's reach, and the fall mat was not positioned next to the bed as required, but instead was folded up next to the Broda chair. Interviews with facility staff, including a Certified Medication Aide, a Licensed Nurse, and an Administrative Nurse, confirmed that call lights should be within reach and fall mats should be placed by the bed for residents who require them. The facility's own policy emphasized the importance of maintaining an environment free from accident hazards and prioritizing resident safety and supervision. Despite these policies and care plan directives, the required fall prevention measures were not consistently implemented for this resident.
Failure to Identify and Report Missing AIMS Test During Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities for a resident with multiple diagnoses, including congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident had intact cognition and was receiving insulin, a diuretic, and an antidepressant, as documented in the Minimum Data Set (MDS) and Care Area Assessment (CAA). The resident was also prescribed Reglan (Metoclopramide HCl), an antiemetic, to be taken before meals for nausea. Despite this, the Monthly Medication Reviews (MMRs) for August and September did not include documentation or recommendations for an Abnormal Involuntary Movement Scale (AIMS) test, which is necessary to monitor for adverse effects associated with Reglan. Interviews with nursing staff revealed that AIMS testing was not completed for the resident, and the facility was unable to provide evidence of an AIMS test when requested. The administrative nurse acknowledged that the CP should have identified the lack of an AIMS test and that the issue was brought to the attention of both the CP and the corporate office. The facility's policy required the pharmacy to have access to complete medical records and the ability to document in the resident's record, but the deficiency occurred due to the CP's failure to identify and report the missing AIMS test during the monthly drug regimen review.
Failure to Monitor for Adverse Effects of Reglan
Penalty
Summary
The facility failed to ensure appropriate monitoring for adverse effects of the medication Reglan (Metoclopramide HCl) for a resident with diagnoses including congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident's medical record documented the use of multiple medications, including insulin, a diuretic, and an antidepressant, and indicated intact cognition. The care plan specified that medications would be administered as ordered and that the resident would be monitored for side effects, with documentation of effectiveness. Despite a physician's order for Reglan to be administered before meals for nausea, the facility was unable to provide evidence of an Abnormal Involuntary Movement Scale (AIMS) test or any other method of monitoring for side effects related to this medication. Staff interviews revealed that AIMS testing was not triggered for this resident because Reglan was not classified as a psychotropic medication in the facility's system. Additionally, the facility could not provide a policy related to monitoring medication side effects when requested.
Failure to Document Hospice Services and Orders in Resident Records
Penalty
Summary
The facility failed to provide a comprehensive description of the medication and equipment supplied by hospice services for a resident with diagnoses of congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident was admitted to hospice services, but the Electronic Medical Record (EMR) did not include an order for hospice admission, and the order provided was only found on the hospice provider's certification form. Additionally, the Significant Change Minimum Data Set (MDS) was not completed following the resident's admission to hospice, and the Care Area Assessment (CAA) was not completed within the required 14-day period after the MDS was initiated. The resident's care plan documented the frequency of hospice nurse and aide visits but lacked details regarding the specific equipment and medications provided by hospice. Interviews with facility staff confirmed that care plans and Kardexes should include hospice information, such as equipment, medications, and services, but these details were missing. The facility's policy required written identification of hospice services and a physician's order with diagnosis and prognosis, but these requirements were not met for the resident in question.
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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 Lansing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Oaks Health And Rehab | 0.8 mi | ★★★★★ | 0 | 0 |
| Medicalodges Leavenworth | 3.7 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Platte City | 9.5 mi | ★★★★★ | 1 | 0 |
| The Healthcare Resort Of Kansas City | 10.9 mi | ★★★★★ | 32 | 0 |
| Providence Place | 11 mi | ★★★★★ | 16 | 0 |
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